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BackTable / ENT / Podcast / Transcript #165
Podcast Transcript: Implementing FEES for Infants in CVICU & NICU
with Olivia Brooks, SLP
In this episode, pediatric speech language pathologist (SLP) Olivia Brooks (University of Florida Shands Hospital) shares her experience performing inpatient fiberoptic endoscopic evaluation of swallowing (FEES) with host Dr. Gopi Shah. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Feeding Challenges in ICU Infants: Presentation & Management
(2) Clinical Decision-Making for Bedside Evaluation & Advanced Diagnostic Studies
(3) Choosing Between VFSS & FEES: Clinical Considerations & Protocols
(4) Enhancing Pediatric Swallow Assessments: Implementing Bedside FEES
(5) Building Collaborative Protocols for Bedside FEES in Pediatric Critical Care Units
(6) Team Dynamics when Performing Pediatric Bedside FEES: The Essential Role of the Feeder
(7) FEES Practices: Transitioning from the CVICU to the NICU
(8) Challenges & Solutions when Breastfeeding for Bedside FEES Procedures
(9) Outcomes & Future Objectives for Pediatric Dysphagia Assessments
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[Dr. Gopi Shah]
Hello, everyone, and welcome to the Backtable ENT Podcast, where we discuss all things ENT. We bring you the best and brightest in our field, with the hope that you can take something from our show to your practice.
My name is Gopi Shah. I'm a pediatric ENT, and I have a really awesome guest here today. I have Olivia Brooks. She's a pediatric speech and language pathologist at the University of Florida Health Shands Hospital, where she's part of the research team at the Aerodigestive Research Core Lab. She specializes in neonatal and infant feeding and swallowing disorders, and her research interests include feeding and swallowing outcomes in infants with congenital heart disease, infant and family-centered care models, neurodevelopmental care, and aerodigestive disorders. Olivia has formal training in flexible endoscopic evaluations of swallow, also known as FEES, and videofluoroscopic swallow studies, which we will refer to as VFSS, and neonatal touch and massage. Olivia's here today to talk to us about performing FEES in infants in the inpatient or the hospital setting. Welcome to the show, Olivia. How are you?
[Olivia Brooks, SLP]
I'm doing well. Thanks so much for having me. I'm excited to be here.
[Dr. Gopi Shah]
I'm excited to have you. Can you tell our audience a little bit about yourself and your practice?
[Olivia Brooks, SLP]
Sure. I like to refer to speech pathology as my second act. I was actually an elementary school teacher for many years and planned on going back to speech pathology to go into the schools. Then, about 10 years ago, I had my son, gave birth to him, and he had some feeding issues. I got into graduate school, and I discovered this whole other world that we have as speech pathologists. I fell in love with the medical side and acute care and working with the babies and the families. It's all just snowballed from there, and I haven't really looked back or thought about going back to the schools. I love working in the hospital with these fragile infants and their families and helping them bond and get through the really difficult time. That's, in a nutshell, how that went down.
I work primarily in the neonatal intensive care unit now and in the pediatric cardiac intensive care unit. I also cover general peds, ICU, post-surgical patients, floor patients, really any pediatric unit in the hospital. You'll see me walking around, budging around Shands, but mostly I'm in the NICU- that's my primary home, I would say.
(1) Feeding Challenges in ICU Infants: Presentation & Management
[Dr. Gopi Shah]
That's great. Just to set the clinical stage, how do infants with feeding difficulties usually present to you in the hospital? You can, if you want, divide it by, the NICU babies usually present this way because they're so different from the CVICU babies. Then, of course, the PICU babies.
[Olivia Brooks, SLP]
They are very different, and it depends on where they're at from a developmental stage as well. Our very young premature babies, 32-33 weeks, they're just having those emerging skills and feeding cues. We're working on strengthening their oral motor functions and providing good positive experiences for them with feeding. A lot of my work revolves around positioning them for feeding well and handling flow rates and helping moms breastfeed. They're typically a little bit slower to feed. They might take a little bit longer. We have a level four NICU, so we see very sick infants as well, babies with tracheostomies, babies that have had prolonged NPO because they've had to be on high levels of respiratory support or they've had GI infections and intolerance. From an ENT perspective, we have your typical noisy breathers. A lot of premature babies sort of have that elongated face. They'll have high, narrow palates. They can be born with all sorts of congenital anomalies as well. We see choanal atresia, pretty severe laryngomalacia from time to time will come up. If they've been intubated, we will see intubation injuries, airway edema, things like that.
For the cardiac ICU, those babies are different. Usually, they're term, so they're not premature, not always, but a lot of times they are. They're recovering from open-heart surgery. What we are most concerned about and what started the whole FEES discussion at our hospital was the protocols that we had around managing those patients, particularly those with aortic arch involvement because of the risk to the recurrent laryngeal nerve there and how we were managing those patients. Those patients will fatigue quickly. They'll have cyanosis. They'll need more time to feed. They might need a lot of support to feed efficiently and safely. They'll also have a lot of comorbidities, too, and respiratory insufficiency, so we work with them a lot. On our PICU, it's a lot of trauma patients or, older patients as well we'll see there, too. That's a little bit of a different beast. That's the gist, I think, for them.
[Dr. Gopi Shah]
When you're getting a call for a consult for one of the kids in the NICU, do you have, in your mind, the same sort of H&P? What kinds of questions do you always ask, whether it's the parent or the bedside nurse? Especially in the NICU, we get a lot of our history from the inpatient nursing team. What are you always asking?
[Olivia Brooks, SLP]
I don't know if this is maybe always the best way to do it, but I come at it with a very sort of aerodigestive framework in my mind as I'm going through. I like to get a very clear picture of how each subsystem is working first. I like to start from the top and work my way down. The first thing I do is I go in and I look at the baby. I think that's one of the most important things, honestly, we can do. I want to really lay eyes on that child and look at their tone, look at their state regulation, and listen for things like high-pitched cry. Are they just going from screaming and inconsolable to a deep sleep with no sort of time in between? That's going to tell me a lot about what's happening with their neurofunction.
Then, I'll just work my way down. I'm listening to their breathing sounds. I'm watching their respiratory rate. We're looking for signs of GI difficulties. Are they very grunty, bearing down? They just seem really uncomfortable. They have a lot of flatulence. They're burping everywhere. Trying to tease apart, there's a reason that the physician has consulted me. There's some system that's going awry or could be a multiple set of systems. I like to ask questions around that. Nurses are a great resource because they spend so much time feeding with and working with the babies. They often have them for multiple days in a row. I'll talk to them: how is this baby managing transitions, hands-on time? Are you noticing any noisy breathing? Do you hear a stridor? Does it get worse when they're feeding? Does their breathing get better when they cry? Are we having a lot of vomiting? How are they tolerating NG feeds? A lot of children have to be fed even post-pyloric. Getting a good picture of all of that, I think is really important.
Then another really important piece is the social situation. I want to know how involved parents are, what mom and dad have been able to do. Have they been able to feed their baby? What does that look like? Does mom have certain goals for feeding? Does she want to breastfeed? Does she want a bottle feed? Where we're at with the family situation, what their expectations are. Different levels of care require different expectations, I think, around oral feeding. Has somebody even had a conversation with the straight G2 baby about what the prognosis is for full oral feeds in the next week or two, or however long we think that the child will be with us in the hospital?
I can tend to break it down like that, just to get a good overview of all the aerodigestive systems and try to tease apart where I think the breakdown might be happening. If we need more information through either a FEES or a videofluoroscopy swallow study, then we go from there.
[Dr. Gopi Shah]
I think the point you make about the social situation is so paramount. At least for me, sometimes I don't think I think of it as much as I should, especially when it comes to feeding. I get so fixated on, they've been intubated, and how long were they intubated? Why is there noisy breathing? Yet the parent component, because that's who's going to be feeding the baby and sort of expectations. I think that's such an important point you bring up, Olivia.
[Olivia Brooks, SLP]
I'll just add as a therapist, I think we are a little bit better equipped to do that sometimes than the surgeons. We're doing therapy with these patients as well daily. Feeding is a very intimate, dynamic process, and that's not something that I think you as a surgeon, you're always able to capture if you're just coming in and doing an eval, but we really can. We can spend a lot of time. We can spend more time, I think, often than what you might have available, so I encourage you to use your therapist for that.
[Dr. Gopi Shah]
Yes. No, it's huge. It's a huge component of the overall care for the baby and the outcomes. You mentioned looking at the baby, evaluating the breathing and the respiratory rate, grunting, all those things that just by looking. What else is part of your physical exam when you're seeing these babies?
[Olivia Brooks, SLP]
I include a full body exam. Again, we do the same thing whenever we're doing the physical exam, starting from head to toe. Some big things I look at are the baby's tone. How are they maintaining their posture in space with gravity? Are they high-tone? Are they very low-tone? Looking for things like torticollis, plagiocephaly. I'll do a full oral mechanism exam and cranial nerve exam to the best that I can. Really evaluating the palate and the gums and the way the tongue is moving. Is it able to lateralize? Does the baby root and gape? Are all those oral reflexes intact? Look down, look for any retractions, move down to the chest. This is, I think, really important, particularly for feeding. Our chest wall development, it's impacted greatly, especially with our premature babies and our cardiac infants who've had their chest open. We look for things like pectus. Because they're laying in bed for prolonged periods of time, they don't get a lot of time sitting up, which a typical baby would, where that helps to pull the ribcage and the lungs a little bit more downward. Even for older infants that have had a prolonged stay, they'll have things like shortened looking rib cages, retractions, and diaphragms.
Oftentimes with our cardiac infants or our infants in the NICU, if they've had gastric surgeries at all, that does happen quite frequently, or they've had chest tubes, or they've had pacer wires, and they've had an incision, I like to look at all that scarring because you can have a lot of banding down and tightness. The scar tissue will just get really adhered to the stomach and the diaphragm, and that can affect the way that they're laying and breathing. I want to make sure if I see anything like that, I'm prepared to do some massage and work some of it out, but also make sure that we have some PT and OT working with these babies.
Move down to the hips, see how our hips are working and moving, because if that's all out of alignment, that really affects their feeding efficiency as well. Then even down to the legs, what is their tone looking like? How is that helping maintain posture for feeding? Just start at the top and really work my way down.
(2) Clinical Decision-Making for Bedside Evaluation & Advanced Diagnostic Studies
[Dr. Gopi Shah]
Which babies are you going to try a bedside eval, whether it's to try a little bit of oral bedside versus, "Hey, I think we need to do more studies"? What tips you off for the next diagnostic workout? Usually, we think of the video swallow versus a FEES.
[Olivia Brooks, SLP]
That's a good question. I wonder if sometimes I'm a little aggressive with that. I am a big proponent of, I want to be very prepared for any procedure that I'm doing on an infant, especially a fragile infant on an ICU. I like to work with that baby quite a bit before we move towards even a videofluoroscopy, certainly a FEES. That depends on a lot of factors, but the big ones for me are, is the baby stable? Physiologically stable to where I can move the baby without them losing their minds. They're able to maintain their state. I'm able to position them well for that study. What levels of respiratory support are they on? We know that higher levels of respiratory support can set infants up to fail because especially if we're providing something that's like a CPAP or it's meant to stent the airway open to help them out, but then they're not going to have as robust of laryngeal vestibule closure during the swallow.
For infants, it's really important to remember what we're asking them to do during a feed is suck, swallow, breathe, every second. We want it to be one to one to one. That's a little apneic event every second that we're asking them to do. It's much faster than what you and I do. They need to have some sort of respiratory reserve. If we're providing CPAP, it might feel like I'm asking them to swallow with a leaf blower in their face. I can imagine. I like to put myself in their shoes. Maybe that's not the best time to go ahead and evaluate swallow.
Once they're weaned from CPAP though, I typically do go to bedside and I'll do small volume PO trials with me and we'll get a good plan together with occupational therapists who are wonderful resources and help us out quite a bit with that and watch how the baby does. Once we start feeding, are we noticing any bradycardia, desaturations, things like that? If we are having some instability, I might wait. I might say, I want to work with this child for a few more days before we attempt to go digging. It depends a lot on the child, but I do like to work with them and have a good plan in place to set them up for success for the study. I think that that's really important, as long as we can do it safely and our teams are comfortable with it, which I would say they're very supportive of that. Even if it's just us coming and doing the oral feeding, they'll typically allow us to come in and use our clinical judgment with that. Worst case scenario, I do like milk drops or paci dips. I'll do that a little bit if they're on CPAP, if they're otherwise stable and looking good.
[Dr. Gopi Shah]
This might sound like a silly question, but when you say I'm going to work with them a few more days, that's if the baby's only at paci dips, we're going to keep doing that for the next couple of days consistently so we get that part down, or we're going to do, "Hey, they can do 10 mLs once and let's see how they do for a couple of days." Is that what that means, or are there other things that you're doing?
[Olivia Brooks, SLP]
We might need to play around with some things too. One feed sometimes just might not be enough for me. Sometimes it is, but sometimes I need to get to know the baby a little bit better. Some of our cardiac infants especially, they'll be intubated shortly after birth and they might not get extubated until after their surgery or their repair and they haven't had any practice. I think it's really important to give them that and allow them to show. They're going to be disorganized. Oftentimes, they'll be gaggy right after they're extubated. They're weaning from a lot of medications and the medical teams will be like, "Okay, they're ready to eat. They're weaning from CPAP," but they're not ready yet. They need a little bit more time. I'm happy and I enjoy going and working with them in those moments and figuring them out and learning them, but they might need to get to a little bit of a better place before I'm ready to scope them. That's an invasive procedure. What I tell my teams is, I want them consistently and efficiently taking 5 to 10 mLs. I can get a pretty good study from that before we move to the FEES or the VFSS, either one.
[Dr. Gopi Shah]
That's going to be my next question. How do you decide which one you want to use? Which study?
[Olivia Brooks, SLP]
Oh, that's a good question. That's fun.
[Dr. Gopi Shah]
That's a podcast on its own, Olivia.
(3) Choosing Between VFSS & FEES: Clinical Considerations & Protocols
[Olivia Brooks, SLP]
Well, I could talk about it forever. I won't though. I think that for the longest time, VFSS was the gold standard, and we still consider that to be the gold standard. Now with FEES becoming more and more popular, there are many people who also think of that as the gold standard. We have two very separate and distinct exams that give us distinct information. I'm actually stealing this from my dysphagia professor, but the platinum standard would be to have access to both, and different babies will do better and participate better for one versus the other.
Age is a big factor. I think FEES works great for young infants who have that reflexive suckle intact and are food-motivated. We can get them hungry. We can take advantage of that suckle reflex and that usually works very, very well. Once they get about five, six, seven, eight months of age, it becomes much harder unless they're very food-motivated because they start to have very big opinions about you having a scope in their nose and eating at the same time. Two, three-year-old children, even worse, I rarely do a FEES in that age unless, again, we have just a very food-motivated, very compliant child, which does happen occasionally. For those children, I tend to lean more towards the videofluoroscopy swallow study because I can make that a little bit less scary, I think.
Otherwise, for our critically ill patients, the FEES is a great option because we don't have to transport them. We're not exposing them to unnecessary radiation. Some children need both. It depends on what I'm seeing clinically that will have me lean towards one side or the other.
On our cardiac ICU, we have a protocol in place that says that after the aortic arch procedures or any infant that had a sternotomy, six weeks of age, those children, they must have some sort of instrumental assessment of swallowing. This is coming from our cardiothoracic surgeons, so that's something that they feel very strongly about. That team, in that unit, really prefers the FEES because taking those patients down to fluoro is, as you can imagine, quite the endeavor. They like to get the airway evaluation at the same time because of the risk of vocal fold impairment. Also, it's very easy because we're feeding the babies in our arms. We can try a lot of positional strategies that we might not have as easy access to down in fluoro. For instance, if we have a left vocal fold paralysis, we would try to feed that baby lying on the right side to see if that helps. With airway protection, we can feed them whatever they're typically eating so we're not having to give them a barium contrast. The team really likes that and they really prefer that. Sometimes though I will have a baby that I'll say, this child has got some aversive behaviors going on. I don't think a FEES is going to work. I would like to go straight to just fluoro and then have the ENTs come and do an airway evaluation if they need that. Sometimes that will still happen. That was our original protocol. Typically on the cardiac ICU, we aim to do a FEES first per the cardiothoracic surgeon's mandate there.
Otherwise, like if I'm in the NICU, it's really what I am seeing. If I am concerned about airway issues and I want to see that as well as the swallow function, then I will attempt the FEES. If I have a baby that from a respiratory reserve perspective, I don't think they'll do well with me including air by using the scope, then we'll opt for the video swallow study. If I'm more worried about esophageal issues and I want to do an esophageal screen, obviously I need fluoro to do that. Some of our patients with strokes, HIE, I need to see what's going on in the mouth with the tongue and how that's moving, then videofluoroscopy is probably a better option for that. It depends on what I want to see, what the skills of the baby are, what the parents' wishes are, and the team as well, what questions they have that maybe I can help answer as well with whatever study I choose to do. Does that answer the question?
[Dr. Gopi Shah]
Yes, it does. I think the way you explained it's super helpful because I think the FEES versus video swallow is always something that I always have to take a second and think about what information, what's the question and what am I looking for? Then, I have to think about what's actually happening in both of the tests to then help me decide what's helpful. I like the points that you make about being able to do an evaluation bedside and not having to transport a baby with the FEES, being able to try different positions bedside.
I wanted to talk to you a little bit more about the inpatient, bedside FEES. You said that this all started with the cardiac babies. Initially, those babies would get a video swallow, an ENT would come and do a scope bedside to look at vocal cord function to the main question. Then, tell me sort of the evolution of, wait a second, why are we sending these babies down to fluoro, can we do this whole bedside?
[Olivia Brooks, SLP]
It started with me, I think, getting a little frustrated with that protocol from time to time. As soon as the patient was extubated, that morning, they would be extubated at 9:00 AM and at 9:02, ENT had consented, yes, and poor ENT was running up from the OR to try to scope the patients. They're freshly extubated, probably on BiPAP or something, and the cardiothoracic surgeons are just ready to go at that point. As soon as ENT's evaluation was done, we would have so many conversations around what the findings were.
[Dr. Gopi Shah]
I'm glad you say that because they're never that clear that early on, right?
[Olivia Brooks, SLP]
Exactly.
[Dr. Gopi Shah]
There's like, "Oh, can't get the best view? Maybe it's weak."
[Olivia Brooks, SLP]
There's so much edema, yes. Then, they would say, if there's a cord out, the cardiothoracic team would really start to then push me off a little bit and say, "Well, we want to see if the vocal fold is going to get better or, you can do like little bits, PO, but let's hold off on the swallow study." Or the opposite would happen, they would say, "Oh, well, the cords are compensating, everything looks good, so you have to do the swallow study like now, today." We just started having these evolving conversations and I tried to make the case that just because a vocal fold is out, that's not a functional swallow assessment. What they need is that: they need a functional swallow assessment and that gives me some good information of some things that I can try when I'm doing my swallow assessment, but I didn't like being told that the baby couldn't eat because of that and vice versa, that the baby could eat because the vocal fold was moving because a lot of those patients without vocal fold paralysis still aspirate. There's a multitude of reasons why that would happen.
It evolved from there. I was feeling frustrated. I don't know if ENT was feeling frustrated, but I think that they might have been because they're having to come up from the OR and I wanted to do this. I had this thought, I said, "I think I can do FEES on these patients and we can maybe set them up for a little bit more success." My hope was that we got better information at a more appropriate time that would help the babies not be rushed to a G-tube or have to have multiple video swallow studies and be exposed to multiple bouts of radiation and have to come up the unit and it's a big thing.
I went to my manager at the time, Dr. Carrie Linnaeus, who's extremely supportive and she sent me to Baylor. They have a neonatal FEES course there with Jenny Reynolds, who's awesome. I did that training and then I came back and I just asked ENT, I said, "Listen, can I practice with you guys?" Because there was nobody at our institution, we have separate competencies for peds and adults. Even though I was competent to scope adults, I was not competent, technically, to scope the infants. I wasn't even sure if it was something that they would tolerate because obviously, the scope would have to be in there a little bit longer. We would have to have them up out of bed, all of these things. I was very, very fortunate that I was supported by my ENT colleagues and they allowed me to tag along and they taught me how to scope the patients. I started off just helping them with their bedside evals that they would get on the cardiac ICU. They would allow me to tag along. The MD was present, she would teach me and I would just do the scoping part. My management was very supportive of that too, because technically that's not something I can bill for because I wasn't doing a functional swallow. I was just practicing, after I had gone to Baylor and practiced there and all of that. I got pretty good at it and we had a set plan that I was going to do so many with them. I kept a rudimentary tally on my post-it note and every time I would go with them, I would just do it. I'm sure there's better ways to do that. Then once I got to our number that we said that they wanted me to do with them, I sent a message to Dr. Bill Collins, who I think has been on your podcast.
[Dr. Gopi Shah]
Yes. Shout out to Dr. Collins. The chair now.
(4) Enhancing Pediatric Swallow Assessments: Implementing Bedside FEES
[Olivia Brooks, SLP]
Yes. I told him, "Hey, I've done this many. I feel like I'm ready to start trying to do this on my own. How many more would you like to see?" He was in my office 10 minutes later and he signed my competencies. That was the first big step was even figuring out how my institution wanted me to get those competencies signed. Then, the next big step was convincing the cardiothoracic team of this. That was a whole different beast. I would say working with the ENT was much easier, but the cardiothoracic team, and I'm actually very grateful that they did this now. I brought it to them and I explained why, they listened to me and I'm very grateful for that. They heard me and they said, "Okay, here's the deal. We want a safety plan in place. Tell me what your safety plan is going to be." I got to work and I wrote up a protocol and I said, "This is going to be the safety plan. We're going to have blow by. The patient's going to have worked with me before, so I know that they're stable enough to do this. We're going to have blow by available. We're going to have suction available. A nurse is going to be in a room. There's going to be two skilled clinicians in the room, an endoscopist and a feeder. This is what we were going to do if we needed to abort the study." I outlined just some criteria for patients that were appropriate. They need to be weaned. We just made a decision to do two liters or less, unless that's acting as CPAP, like the baby's very small, but I wouldn't do a FEES on an infant like that anyway. We just said two liters. They couldn't have any transthoracic lines in place. Those needed to be removed. They were stable and working with us before and they were able to get out of bed. We had a whole list of criteria.
Then from there, they said, "Okay, this looks good. We like your plan. We want to come watch 10." We want to be present for the first 10 that you do. We just want to see. I think that they watched one, maybe two. Then they were like, "Okay, you're fine. Go on with it." Once they signed off on it, and now we have all these nice, really helpful protocols that I've used to train other speech therapists on how to do this. It's been a nice snowball effect. We have two other pediatric clinicians now who are endoscopists and do wonderful work, and I feel like it's helped us all grow. I'm grateful to the physicians that really took me under their wing. I think it was a labor of love in the beginning, but now I hope they feel like it's paying off.
[Dr. Gopi Shah]
Oh, I'm sure.
[Olivia Brooks, SLP]
It's helpful they're not having to run up from the OR.
[Dr. Gopi Shah]
Yes. It's good for the baby, right? It's better care. When you were learning to scope initially, were all your scopes recorded? Could you go back and look at them? Was it not only just the physical passing of the scope, but also assessing vocal cord mobility and laryngeal function as well in the initial training period?
[Olivia Brooks, SLP]
When I was practicing with ENT initially, we recorded the laryngoscopy part?
[Dr. Gopi Shah]
Yes. That's what I mean.
[Olivia Brooks, SLP]
Yes. I actually did do that when I was doing research at the Aerodigestive Research Core for that year, we actually videoed me scoping everyone too, so that we could time it up for research purposes. I will say that it was extremely helpful to me to go back and watch myself because I certainly realized some issues with my posture. I changed how I was doing it a little bit because I was able to go back and watch and see how I was holding it. I would recommend that you do that even though I didn't do it initially. So I like to know what I'm looking at, but I also feel very strongly that as a speech pathologist, my scope of practices and not overstepping that.
Yes, in answer to your question, certainly we would go over the videos together with ENT because even still now our images are sent to a shared ENT folder for ENT to review should they need to. I don't diagnose anything. I think that that's an important distinction. It's just something that I've had to really talk with our teams about because now they only want FEES sometimes and they'll say, "Can you just tell us what the airway looks like?" I'm not an airway physician. That's not my scope. ENT, if you'd like for them to be consulted and review the images, they can give a diagnosis. I cannot give a diagnosis. I can describe what I see, so that's what I do. We would go over the videos together and talk about it. I was given the opportunity to ask questions and that was very, very helpful because even just noticing little things like, am I suspicious that it's not a vocal fold paralysis, but there might be some laryngomalacia or something in there that I think ENT might want to just be alerted to or whatever. I think that it's very helpful that I am able to see those things and not send frivolous referrals to you guys, things that actually you want to see and it's a good use of your time as well. I was given that opportunity and I think it was good, but as far as my report and all that, I'm only commenting on swallow function and I can describe what I see, but no diagnosis other than dysphagia, if it's there.
[Dr. Gopi Shah]
If there's something that you're questioning or if the team wants to question, there's a shared folder of all the FEES that are recorded. That way an ENT can look at it?
[Olivia Brooks, SLP]
We only put in the consult for ENT into the shared folder. Not all of them go in. I'll be honest. I'm a little bit privileged because my partner's a peds ENT, so if sometimes if I'm on the fence about something, I'm able to like upload it and just say, "Hey, can you just take a quick look at this whenever you get a second and tell me if you feel like this warrants a consult to you before I throw a big stink about it and get everybody involved." I don't have to do that as much anymore because I'm learning as I go. We only upload them to that shared drive if we want ENT to take a look at it. Not all of them get that because we do have the protocol on the cardiac ICU and a lot of those scope exams are fine. They're functional. Their airway is very stable. They're feeding just fine. They're not aspirating. We don't clog it up with things like that.
[Dr. Gopi Shah]
Most of them will have already had a scope anyways if they had cardiac surgery by ENT. They may see a consult for a vocal cord evaluation? No?
[Olivia Brooks, SLP]
No, we've replaced that only if it's indicated now for ENT to come scope. That was the point, was that we were minimizing how much instrumentation.
[Dr. Gopi Shah]
Yes.
[Olivia Brooks, SLP]
Because we have access to the videos, if anything pops up, we can always send it later too. ENT is consulted typically after our initial FEES when we need them to review the images for whatever reason. We had a baby last week that had a FEES, had left vocal fold paralysis, and was aspirating. ENT looked at the images, confirmed. We worked with the patient for about a week. We did some therapy. We had to thicken up a little bit, things like that. Voice spontaneously got better and then ENT did come back and re-scope and we ended up taking that baby for a videofluoroscopy because we wanted to also check the esophagus for something which was unrelated. Things like that happen where I'm not saying ENT never comes and scopes because there are certainly reasons to do that and they do do that. For that post-cardiac surgery protocol, it's not mandated anymore that ENT come unless we need them to.
(5) Building Collaborative Protocols for Bedside FEES in Pediatric Critical Care Units
[Dr. Gopi Shah]
In terms of the safety plan or the protocol, how did you know what criteria? Were there certain references? Was it just talking to other colleagues working with the CVICU team, RT? How did y'all come up with it?
[Olivia Brooks, SLP]
It was all of that. I wanted to know what the cardiothoracic surgeons, what their hard stops were. Honestly, they didn't have as many as I had. The transthoracic lines, I think, are the big ones. They don't want the babies moving or getting out of bed with those. We had some discussions around art lines and UACs and how we can manage those things. It got really into the nitty gritty details, but I like that because I think it helps just set clarity from the beginning. We were able to say, "Hey, we can position the baby and secure an art line like this using these clamps. We feel pretty good and safe with that." I think they were open to it. I also included a caveat in there that the baby otherwise has to be stable from a respiratory perspective and just from a neurostate regulation perspective. If they're not, then we might need to hold off for a little bit. That gave me some, I think, flexibility and wiggle room if I need to make a case to wait a little bit longer.
They're very resilient. We've definitely done over a hundred of these on the cardiac ICU now. We've had one instance of a nosebleed and some of them, we'll get a little tachycardic and we have to watch that closely, but thankfully, knock on wood, we've had no other adverse effects. They're very resilient. I think part of that is timing it well and making sure that you have these kinds of boxes checked off. I'll say if anybody wants it, I'm happy to share, you guys can email me or whatever. So you're not starting from scratch if somebody wants to do that. That's how we worked through that.
[Dr. Gopi Shah]
Was it hard to convince the bedside nurse, the CVICU nursing team, or the RTs for this protocol?
[Olivia Brooks, SLP]
No, they love it because they don't have to leave the unit. They ask for it. Sometimes I have to fight them about it, like, "No, this baby needs a videofluoroscopy. Trust me. I'm sorry. You got to bring them down." "Can't you just do the scope?" I've been there almost seven years now and a lot of it is about finding your team and building trust with people. I hope that they trust us for the most part and that we've picked the best exam for that baby at that moment in time. We're trying to make the best decisions for the patients and the families.
(6) Team Dynamics when Performing Pediatric Bedside FEES: The Essential Role of the Feeder
[Dr. Gopi Shah]
The feeder can be another nurse, a parent, another speech pathologist? Who's the feeder?
[Olivia Brooks, SLP]
That's a great question because I'm very picky about that.
[Dr. Gopi Shah]
Yes, you're the endoscopist, so who's the person feeding? Because that's your partner in doing this.
[Olivia Brooks, SLP]
Yes. We've found what works best, this may be different for different institutions and different endoscopists. I'm very picky about who the feeder is. I think it's the hardest job on the team at that moment. I want that feeder to be a very skilled feeder who knows this baby intimately and has been working with the baby. What we have found, what works best for us, 9 times out of 10, it's going to be either a speech pathologist or an occupational therapist. We usually have three people on our team. We have the feeder, who's the primary feeding therapist for that baby, that would be either a speech pathologist or an occupational therapist, endoscopist, and we also have an assistant, which can be the nurse or a lot of times med students like to come in and watch and they'll help, or a graduate student or something like that who can help us hit record. We do pacifier dips of sucrose sweeties or breast milk like two minutes before we pass the scope just for that very short-term analgesic effect. They help with all of that and keeping track of what strategies we've tried and when and time stamping and all of that.
We need at least three people and I'm very picky about who the feeder is. There's probably some controversy with this. I try not to let parents feed if it's at all possible. I just find that they get a little bit overwhelmed by it and we're really providing a lot of containment during the feeds and the positioning and the ergonomics is so important. It takes longer to set up for it than it takes to actually do it oftentimes. They want to rock and shush. What works for me is I explain all this to the parents. I like for them to be there, though, in the room because part of our protocol, which we also had like this whole other leg to it, which was neurodevelopmental care was, immediately after the FEES, the feeder gets up, I back up, the parent sits down, we hand the baby and they do some skin to skin and calm and like set to a pacifier. I tell the parents that's their job. The babies might cry for a minute. Sometimes they even don't, but they might cry. We're going to ask them to eat. We're going to ask them to run a little bit of a marathon here with us and work with us so we can get some information. As soon as we're done, this is what's going to happen. I'm going to get up and back up. Julia or whoever's feeding is going to stand up and I need you to come in and sit and hold the baby and calm them for at least 15 to 20 minutes.
That also gives me a little bit of time to review my images and get everybody nice and calm and in a good state so that I can talk to the family about what I saw, what my recommendations are going to be, if we're going to get ENT involved, if we're going to start feeding, if we're not going to start feeding. I think that it gives them some ownership still without having to let them feed at that time. I think it's just hard with all the lines and everything too. It's a different beast.
(7) FEES Practices: Transitioning from the CVICU to the NICU
[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.
(8) Challenges & Solutions when Breastfeeding for Bedside FEES Procedures
[Dr. Gopi Shah]
In terms of tips and tricks, I think that the point about the ergonomics is important. I think that the experience of filming yourself, I don't think we do that ever or enough. If anybody's ever even done once, I'm sure if somebody filmed me even doing a tonsil, they'd be like, "Look at your bed could be a little bit higher. Your neck is completely cracked over. How are you holding--?" I'm short. I've been doing it forever. The ergonomics and filming yourself, what are their tips and tricks? Is there a certain way you like to have your baby swallowed? Is there a certain side of the bed that you stand on? Anything like that that seems to help you?
[Olivia Brooks, SLP]
Sure. We have everything set up ready to go as far as what bottles we're going to use. I'll have nipples lined up with different flow rates so that very quickly we can switch things out. I'll pre-thicken some bottles. Usually, I'll have an ounce of thin liquid. Then, depending on if it's breast milk or formula, for formula I'll thicken that up in a little bit of a larger quantity and then I can toss it later. Breast milk, I tend to be a little bit more protective of. I don't want to thicken and then not use it and have to toss it, but we will thicken up a little bit using a product called Gel Mix, which I really like, and nectar. We go thin, slightly thick, mildly thick. Those are the new terms, or you could say thin, half nectar, nectar. We have a little bit of organic food coloring that we put in, like a dye. I go white, green, white. I just think the white shows up really nicely on the scope, so I'll just dye it, make it a little bit more of a brighter white. I go green for the slightly thick, so there's some contrast. I go white again if we have to go to full nectar, because at that point, we can see if there's something new. That's how I set it up. Obviously, we've worked with this baby before, so we know what nipples and positions have been working well clinically, and we just start there.
[Dr. Gopi Shah]
What about the baby that's breastfed, the baby that ended up with some sort of blue cyanotic event at home, newborn, maybe born 37 weeks gestation, now is 10 days, was getting breastfed at home? For the bedside FEES, we've mentioned a feeder and bottles, but do you ever do these with mom, like breastfeeding FEES?
[Olivia Brooks, SLP]
We have. It's not as common, I would say, but we have done them. I'm still working out the best way, I think, to do those. They're a little bit more challenging for me, I think, just because we don't do them as often. The first few I did with ENT were really rough, to be honest, and I really sat down afterwards, and I was like, I don't know how to do this well. I don't know how to get my position right to where I'm not irritating the baby so much, and the mom's very stressed. It didn't feel as natural to me as the bottle-feeding one does. I think we've gotten a little bit better about that. I just tell the mom, listen, we're going to be good friends. I'm going to be up in your business, and we're going to get through it together, and they're usually laughing. They'll be all right with it. I almost just straddle her, and her legs go, for lack of saying it nicer, between mine, and I just scoot right up. Again, depending on mom's breast size and shape and how little the baby is, if they can latch first and go, and then I insert the scope, I think that works a little bit better. If that's not working, then I just try to have the baby as close to mom's breast as we can.
What I do is I have the assistant, whoever's helping me out, drop a little bit of the food coloring from a syringe on mom's nipple right in the corner of the infant's mouth whenever the child does start to nurse, and I just manipulate the scope to get to where I can see the best view. We do them, yes, in answer to your question. It takes a little bit more finesse, finagling, and it's not as common, so I'm not as skilled, I feel like, in that. I think we're learning as we go with those, but we can, and we do them. I've had some really good ones, and I've just had some ones that just didn't work at all.
(9) Outcomes & Future Objectives for Pediatric Dysphagia Assessments
[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.
[Dr. Gopi Shah]
Thank you so much, Olivia. Are you on any social media if any of our listeners want to reach out to you or have questions? Otherwise, they can always reach out to us on BackTable and we can get that to you as well.
[Olivia Brooks, SLP]
Yes, you can email me. I'm not big on social media. I do have an Instagram, you're welcome if they want to send me a little message. I do tend to post some feeding and swallowing stuff on there. I should probably be better about it, but they're welcome to send me a message and let me know that they heard it and I'll be happy to friend them on Instagram. Other than that, I don't do too much, but email is a great way too.
[Dr. Gopi Shah]
Thank you so much, Olivia. This was awesome. I think it's a wrap.
[Olivia Brooks, SLP]
Thank you.
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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