Brainstorms Ep 33
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[00:00:00] Renee: Welcome to Brainstorms Functional Neuro Rehab for SLPs presented by SpeechTherapyPD. com. This podcast is designed for the adult medical speech language pathologist. Most of our audience members work in settings such as acute care hospitals, private practice, Outpatient hospital clinics and inpatient rehabilitation hospitals.
[00:00:28] Renee: Each episode has an accompanying audio course on speechtherapypd. com and is available for 0. 1 ASHA CEUs.
[00:00:42] Renee: The content of this course is based on the research and experience of The presenters. Presenters, the listener, is responsible for researching to determine if the information and skills taught are appropriate for their client, students, or patients. Speech therapy pd.com does not necessarily endorse, recommend, or favor the information shared nor any of the claims, opinions, statements, offers or services made by the presenter.
[00:01:06] Renee: Hello and welcome everyone. My name is Renee Garrett and I am your Speech Therapy PD. com podcast host for Brainstorms Functional Neuro Rehab for SLPs. Before we get started, we have a few items to alert you to. Each episode is 60 minutes and will be offered for 0. 1 ASHA CEU. Here are the financial and non financial disclosures. Nicole DePalma is the owner of Endoscopy Dysphagia Specialists. She is also a Passy Muir consultant and the president of Tracheostomy Education. Nicole DePalma receives an honorarium for her participation in this podcast from speechtherapypd.
[00:01:47] Renee: com. She has no relevant non financial relationships to disclose. My financial disclosure is that I'm a paid employee of a private consulting firm in the Commonwealth of Virginia. I'm also an adjunct instructor for both James Madison University and Old Dominion University. As the host of Brainstorms, Functional Neural Rehab for SLPs, and other webinars on speechtherapypd. com,
[00:02:13] Renee: I do receive financial reimbursement. My non financial disclosure is that I'm the secretary for the Communication Disorders Foundation of Virginia. Questions can be written in the chat box or the Q& A and will be answered at the end of the presentation. Now, without further ado, we welcome our guest, Nicole DePalma, MS, CCC, SLP, who is the owner of Endoscopy Dysphagia Specialist.
[00:02:40] Renee: She received her bachelor's degree at Georgetown University and her master's degree at New York Medical College in Speech Language Pathology. She has over 15 years experience of 15 years of clinical experience working with patients with dysphagia, including the medically complex, such as those, those with tracheostomy and mechanical ventilation.
[00:03:03] Renee: Nicole provides competency training for SLPs. interested in FEES. She also provides tracheostomy consulting for developing and implementing new protocols and performance improvement strategies and providing comprehensive education to clinical staff. Before endoscopy to stage a specialist, she was the director of clinical education at PASI mirror incorporated.
[00:03:27] Renee: She has also worked previously as director of speech language pathology at Barlow respiratory hospital and research center in Los Angeles, California. Nicole is president of Tracheostomy Education, providing in person and remote courses for universities and facilities nationwide. Welcome, Nicole. So nice to see you.
[00:03:49] Nicole: So much for having me. I'm so excited for this presentation.
[00:03:56] Renee: Oh, good. Good. Well, welcome. I think we've crossed paths a couple of times, but never actually met. So, thank you for, you know, reaching out and agreeing to be a part of this, because I think it's really important to talk about what we're going to talk about tonight.
[00:04:11] Renee: I think so many SLPs and even audiologists have moved into this realm of trying to figure out how to have their own business, whether it's like a side gig or a full time thing or start out as sort of like a more of a virtual or like almost like a version of home health versus having a brick and mortar.
[00:04:31] Renee: So I think it's, it's interesting to have this conversation. So can, You talk to us a little bit just about why you started the mobile FEES business.
[00:04:41] Nicole: Yeah, sure. So FEES. for anyone that doesn't know, stands for Flexible Endoscopic Evaluation of Swallowing. It's a procedure where a small scope is placed in the nose, looks down the throat to check, you know, to make sure a patient is swallowing safely.
[00:04:57] Nicole: So kind of as a bird's eye view of the upper airway. So I started that business because there was kind of a need for fast. Reliable instrumental swallow studies. So I was working in a skilled nursing facility, and we noticed that there was just, it took a lot of time to get instrumentals for the patients, and sometimes weeks, months, sometimes we never, they never even got scheduled, because you had to rely on.
[00:05:22] Nicole: Nursing to schedule them. Often once they did go out for those swallow studies, we never got the reports back for whatever reason, or we'd have to chase them down. So those were all very, you know, difficult to provide good patient care for the patients at those nursing facilities. So, and also with modified barium swallow studies, those you know, you have to again, transport the patient out to the hospital that can be even costly for the facility that patients out of the nursing facility for a long time.
[00:05:56] Nicole: So they miss their therapy. So, yeah, so I started mobile FEES so that patients can have a little bit better access quicker and, be able to spend, you know, a lot of time with the patient and with the treating clinician because that's missed too. When you send a patient out for a modified is it's just kind of that one clinician.
[00:06:15] Nicole: They might get some information, but when you have FEES, you typically, this is what we try to do or what I like to have is, For the treating SLP to come with me and make sure that, , they provide all the information about what's going on with the parent patient. And they also are involved in like, Hey, let's try this compensatory strategy that might work to help, you know, reduce any.
[00:06:41] Nicole: aspiration or residue or whatever it is that the patient that's going on with the patient. So, yeah.
[00:06:49] Renee: Yeah. It's always interesting because I've been on both sides of the, well, I've been on really, I would say three sides of the coin, even though there's not three sides because I started an inpatient rehab and LTAC.
[00:07:01] Renee: So we had access to FEES within our building. So, there were four three SLPs on our team that were full time and one part time. So we all were FEES. competency trained and perform them every day. So I had immediate access. And if we had the need for a modified barium swallow, even from our facility, we had to transport them to our we called it the mothership, our, our main hospital that wasn't the inpatient rehab facility which, you know, again, could be costly and just time consuming and a burden on the patient.
[00:07:34] Renee: Their family, I had to be, if it was my patient, I had to be the one to go to physically to the hospital. So there's a lot of barriers in that setting. if you don't have modified barium in house. And I know we're talking about FEES, but I just kind of wanted to piggyback off of what you said because even in acute care where I primarily did modify bariums every day we did have outpatient appointment slots.
[00:07:56] Renee: And so a lot of times what would happen is we would get people sometimes who would come on to Our schedule who, again, like you mentioned a snapshot in time. And so when I think when I first started in acute care, I was like, Oh my gosh, they're aspirating. Whoa, we got to change the diet immediately. And then I started as I grew as a clinician and had more experience, I started realizing that I don't need to be the one to make that final call.
[00:08:22] Renee: I need to be the one to say, this is what I saw. This was a physiological problem and make sure. Because a lot of the time, the people that were sending outpatients over to me were people that I knew or people that I had had reached out or I had reached out to them because of their patient. And so we had this rapport, which I realize is not the case for every.
[00:08:42] Renee: Facility. Cause we, you know, we had skilled nursing facilities. We had home health folks, SLPs who sometimes would come, which I was always happy because again, I've got like, you know, what, 10, 15 minutes max with this patient, I don't know anything about them other than what I've read in their chart, if I'm lucky that someone sent a piece of paper that said X, Y, Z about what they'd been working on and then an outpatient.
[00:09:06] Renee: It was funny. Cause I worked for the same health system. But our outpatients had to go through the acute care setting. And so I found it funny that some of the people that were still in acute care would make these decisions about the patients I had been working with for four weeks or six weeks or whatever.
[00:09:24] Renee: So it is kind of a really interesting space that you find yourself in as you've moved from, you know, moved to different settings and then, you know, for some, like we had FEES in acute care, but we didn't do them as outpatient. Yeah. So, like you mentioned, it is, it's a huge need and a lot of the skilled nursing facilities here locally in the east coast of Virginia, we, a lot of them have moved to doing contract based FEES, like a mobile FEES.
[00:09:52] Renee: Because it is quicker. It's more accessible. It had, you know, you have the person on site. So you've got the treating SLP there. So, I just kind of wanted to make that roundabout connection because there's a lot of pieces.
[00:10:06] Nicole: I was just gonna say, yeah, and like, I'm not gonna say that these is better than the modified sometimes we use both right because Always, you know, there's different indications for both procedures that some, you know, there's some ideal patients for FEES versus more ideal patients for modified.
[00:10:29] Nicole: So sometimes even, you know, you might do the FEES and say, Oh, well, actually, it looks like it's a little bit more of a. You know, a UES or whatever
[00:10:40] Renee: we need to see the oral phase a little bit better.
[00:10:43] Nicole: Yeah.
[00:10:46] Renee: Yeah, it is. It is interesting though because I think it speaks to, you know, kind of not just your network but your communication where the communication experts that we need to be making sure that we're closing those loops on either end.
[00:11:02] Renee: And so I think, you know, being in person certainly helps that because then if you were to maybe be at another facility and someone has a question, they know how to reach out to you to get the answers because it is, it's, it's a challenge. I don't feel like it, it should be in this day and age with all this electronic access that we have, but it remains to be quite the challenge and scheduling is quite a challenge.
[00:11:26] Renee: I know when I was the only SLP in acute care for a little bit before they finally hired someone I only had four outpatient appointments a week. So you can imagine we were scheduling out three months, four months sometimes. And then during the pandemic, we weren't doing them at all for a little bit of time.
[00:11:44] Renee: So. Again you know, it didn't need, we can't cease the instrumental because of all these other variables. So I think that that's a really important part. So what would you say some of the benefits other than what we already kind of just touched on what are some of the benefits to the mobile FEES, other than just, you know, the time, the time turnaround being quicker and the, the access being a little bit better.
[00:12:11] Nicole: Yeah, yeah, like you said we did talk about a lot of that I guess. To further the point about the ease, though there are some patients you just can't even transport, right, especially where it's really difficult, or they have all these tubes connected to them, so that makes, you know, transportation difficult, or you know, you can do longer studies with these, so there's, there's radiation with the modified barium swallow so patients who have fatigue issues might fare better with a fee so that we could do maybe a whole meal to see if, you know, they're fatiguing at the end of the meal and that's causing issues.
[00:12:50] Nicole: And also the fluoroscopy machine kind of turns off in between swallows so you can kind of see the whole entire process. Other benefits we can kind of directly view the anatomy of the patient. So we can view vocal fold mobility. We can view the pharyngeal mucosa if there's any swelling that's attributing to the patient's dysphagia, if there's bulging at the posterior pharyngeal wall, or maybe there's even like masses.
[00:13:19] Nicole: I mean, we don't diagnose what, whether the patient has some kind of cancer, but we could, you know, see if there's anything, then refer, you know, to the correct specialist, to an ENT maybe. But viewing that anatomy enables us to really be able to, you know, maybe get a better treatment for that patient. So is the, does the patient have a vocal fold paresis or paralysis?
[00:13:45] Nicole: And then, you know, you know, maybe we have to do some sort of head turn or something to help compensate. We can also view secretions, which you know, if a patient has a severe dysphagia, we might not even provide food or liquid to that patient, but just viewing those secretions is really important for us to be able to, you know, help that patient with their, with the management, especially if they have a trach viewing secretions, you know, helps us determine if the patient can get decannulated or get their trach removed.
[00:14:20] Nicole: So we want to know, are they managing their secretions? Can they cough those secretions out? So those are all really important things that we could, , really assess with FEES. Other benefits might be again, like that the treating SLP is with us so that she can say, Hey, , during the bedside, though, actually, this is what was happening with the patient.
[00:14:41] Nicole: And that's, we haven't seen that yet during the FEES study. So maybe we continue doing try. Maybe they were coughing on liquids and we haven't seen that. So we continue to provide it until we can kind of mimic what the speech pathologist is seeing. So that she can, you know, know, okay, maybe the cloth is just due to
[00:15:01] Nicole: penetration not aspiration and they're clearing that from the airway. So we know that information. Based on what's happening at bedside. And again, they can tell us about any compensatory strategy that they think might be beneficial. And the patient can also view the, the actual swallow study. So either during the swallow study, we can do some biofeedback and like show them the monitor and say, Hey, You know, you have some material in the air in, in your throat or whatnot.
[00:15:36] Nicole: Some can you try to clear that material and they can use strategies like a hard swallow and see if that works and whatever they can do to kind of help clear that material. So that's, I think, a really great, one of the best things about FEES is that biofeedback tool. And then, yeah, like the turnaround usually for us, like one to three days from consultation.
[00:16:02] Nicole: So instead of waiting those weeks or months, kind of get in there pretty quick, more cost barium swallow. And some studies show that it's more sensitive to Aspiration. And viewing the residue then modified barium swallow. So I think those, I think I hit most of the points.
[00:16:23] Renee: Yeah, no, I think that's excellent.
[00:16:26] Renee: And I, you know, it's funny cause you mentioned the biofeedback and I, the one thing that always got a lot of, you know, especially with our patients with TBI and stroke was that I'd say, Hey, you have a lot of residue. Can you do a really hard swallow? They go, no, I don't. I'm like, well, you have some stuff hanging around your throat.
[00:16:43] Renee: I can see it on the screen. Can you swallow? No, I don't turn the camera or turn the screen. And they'd be like, Oh my God, is that me? Can you swallow? That's like the best thing ever. When patients are like, no, I don't, I don't feel anything. And I'm like, Well, that's great, but I can see it. So can you swallow And they wanna have a conversation about how they're not gonna swallow until until they see it, and then they're like, oh, okay, this makes sense.
[00:17:13] Renee: Or the number one was always you know, when you go and, and you explain what you're gonna be doing and that you're gonna put this tiny camera. Up their nose and they go, oh my gosh, that's gonna hurt. And I'm like, no, it's not too bad. If a person is doing it does it correctly, as long as you don't have anything, you know, anatomically, that's, that's structurally gonna be a barrier.
[00:17:35] Renee: And most of the time I'd get the. Oh, that wasn't nearly as bad as I thought it was going to be.
[00:17:40] Nicole: Right. Exactly.
[00:17:41] Renee: That's one of those things where I think I always laugh because I'm like, if I had heard, if I had had a dollar every time I heard that I could retire by now. But I think one of the important points you made too was about the pharyngeal mucosa because I had a TBI patient that it really speaks to oral care.
[00:18:01] Renee: And it's something that I try to share with my students. That. You know, if the oral care hasn't been performed on someone who's been intubated or even extubated in their mouth breather that bacteria and that fungal growth and that overgrowth of yeast can really progress quickly. And so, I had.
[00:18:20] Renee: gotten in with the scope and I looked and I was like, holy, what in the world? It looked like a cavern somewhere in a mountain. The thrush was so bad. And like you mentioned, we're not allowed to call it that because we can't diagnose it, but we can describe it. And that's another thing. I always try to tell students is that get good at knowing what those anatomical, not only the landmarks are, but being able to describe, with purpose what, not like a creative writing experiment, but describe with purpose what you saw.
[00:18:51] Renee: Was it, you know, something that was edematous or swollen? Was it something that looked atypical based on what you'd seen before? All those kinds of things. So, I thought those were really really important points that you made.
[00:19:06] Nicole: Yeah. And, and back to, yeah, the thrush and the secretions I've seen in there from patients who are MPO just these thick secretions sometimes if they're not getting anything at all.
[00:19:20] Nicole: And sometimes I've gone in there and I couldn't even see the airway like we're just covering everything. So yeah, you can kind of get a really good view of. Of all that, the anatomy, the secretion management, so really important to be able to go from there into, okay, what's the next step? A lot of times if you have like these thick secretions, you need to clear them out, so maybe ice chip trials to try to clear those secretions and get Yeah, a more normal airway or a cut.
[00:19:56] Renee: Yeah, and it's always fun too for the students to see and even like newer, you don't have to be a new clinician, but you can be newer to FEES and having that, seeing the anatomy from that, viewpoint, you see things like cobblestone. Sometimes you see some other like anatomical differences. Some people just, their retinoids are not symmetrical.
[00:20:18] Renee: They're just kind of sit funky. And that's, it's good to see those those, those variants, but then also to be able to see what normal swallowing looks like. And that was part of the, the competency. So, I know that's a question for, that we're going to talk about in a little bit, but What would you say is like the primary reason that an SLP should be referring for an instrumental whether it's a modified or a FEES?
[00:20:47] Nicole: Right. Really? There's not a
[00:20:48] Renee: primary. There's a whole bunch.
[00:20:50] Nicole: Yeah. I mean, I guess I would start with how we're assessing them right at bedside. We're assessing our patients. We're doing, you know, a good history, a cranial nerve evaluation. We're asking questions about how a patient swallowing. Are they having trouble?
[00:21:09] Nicole: And then we're providing food and liquid to these patients to some of these patients to determine if you know, they have a dysphagia. So we determine the behaviors associated with a swallow with swallowing function and observe the presence or absence of signs of dysphagia, including if they're fatiguing or.
[00:21:29] Nicole: And also like their posture and positioning as well. So in terms of referring. I wanted to just go into ASHA a little bit, because they indicate that during non instrumental assessment that may provide sufficient information for a clinician to diagnose oral dysphagia, right? However, aspiration and other physiological problems in the pharyngeal phase can be directly observed Only via instrumental assessment.
[00:22:01] Nicole: So meaning that, you know, we can assess, you know, if they're having trouble chewing the food, if there's residue or pocketing in the oral cavity, and we can diagnose that as an oral dysphagia. During the pharyngeal stage, since we can't see it, we can only suspect a pharyngeal dysphagia, so some signs might be that the patient is coughing or throat clearing when we're giving them food or liquid or telling us that they're feeling foods and liquids getting stuck in the throat those are some signs that the patient's having trouble or just, you know, recurrent aspiration pneumonia.
[00:22:40] Nicole: Maybe they're not even showing signs at bedside, but they have that history. So indications can include concerns regarding safety and efficiency that might contribute to nutritional compromise, pulmonary compromise. For airway safety the need to identify disordered swallow physiology to guide management, need to assist determination of a differential medical diagnosis related to the presence of dysphagia, any kind of medical condition or diagnosis associated with a high risk of dysphagia.
[00:23:14] Nicole: So something like stroke or MS, ALS, those types of things that might. Parkinson's disease. So those kinds of disorders might trigger you to think, okay, this patient could have some kind of pharyngeal dysphagia a previously identified dysphagia with suspected change in swallow function or the presence of a chronic degenerative condition.
[00:23:36] Nicole: So those are all your indications per ASHA for an instrumental. Swallow study. And I love quoting like this. There's this one study that was done that I think is so important because there are a lot of therapists still that you kind of, you know, a patient coughs on thin liquids. So we think, okay, let's just give them thickened liquid.
[00:23:58] Nicole: And if they're not, Waffling or anything, then that means they're safe to provide that nectar thick liquid. However, mild, the mild study showed that patients are at very high risk of. Silently aspirating the thickened liquid. So they're not coughing when we're providing the food and liquid up outside. But maybe they're coughing on the thin, but that could be a good thing that they're actually coughing on the thin liquids because maybe they're actually clearing their airway after giving them those liquids.
[00:24:32] Nicole: So, You know, changing the patient's diet based on a bedside can actually be detrimental sometimes to that patient because they're they could be silently aspirating that thickened liquid. So that's why it's really important to get an instrumental assessment and actually see what's going on in the throat because we can't, you know, see aspiration.
[00:24:55] Nicole: We can't see penetration. We don't know if that's happening. We don't know if there's residue in the throat unless we actually view the swallowing process. Yeah, I think those are the main reasons that we would do an instrumental swallow study.
[00:25:10] Renee: Yeah. And it's important, like you said, that the anatomical stuff too, because you know, you see things in the upper esophageal region to that, like strictures, you can see cricopharyngeal bars, you can see diverticulums and things like that, that would be a cause for referral.
[00:25:28] Renee: And again we can't always see that on a FEES, you can see it on a modified barium. But again, you know, we're looking at both sides of the coin. Because like you said, sometimes when I would do a FEES, there was an indication that I needed to look at something else. Maybe I didn't see what I thought I needed to see.
[00:25:47] Renee: And so we would recommend the modified for that reason. So I think, you know, having that That confidence in that competency, because confidence is one thing like I think would, especially when you, I think when you've gotten really good with the physiology, because it takes for me, I felt like it took some time.
[00:26:06] Renee: That wasn't something that I, we learned it sort of in graduate school in our graduate program, but it wasn't, It was more rote, right? It was like, if you see X, Y, Z, this, this, and this, and then when you see it in action with all these other deviations, it makes it really difficult for you to say with certainty until you've become more competent and more experienced and seeing things and taking courses.
[00:26:34] Renee: And I think when I did my dysphagia course in graduate school, we, we did. Like someone came and did a FEES demonstration with us where we just watched like one, and then we had 25 prerecorded modified barium swallows. That was like a quiz we had to do where we identified, like literally the only thing we identified was if it was normal, if they penetrated, if they aspirated.
[00:26:58] Renee: And that was it. So it's really important you know, to be able to look at. both instrumentals and see you know, if this is happening on the FEES, then maybe you need a different viewpoint. And the same thing happens with the modified. Maybe you need a FEES because what you're looking at here doesn't make any sense of the symptoms the patient's describing.
[00:27:22] Renee: But I do like that. You know, I think we're getting better at making making sure that we're, you know, Doing the best by the patient, meaning I always would describe it as I don't have x ray vision, so I can't see inside of your body. I can't see exactly what's happening. So this is the reason sort of the rationale in the starting point of the conversation about why.
[00:27:46] Renee: We would do an instrumental and why we need that. From a safety standpoint. But also sometimes when you're dealing with physicians or even nursing who, you know, they're both really important parts of our care team. But a lot of times if they've been educated in a certain way or, you know, They have experience where they've heard over and over that thickens better, thickens better, thickens better.
[00:28:08] Renee: Let's thicken everybody's liquids. Let's put them all on pureed. We don't really need to do an instrumental because pureed and nectar thick is the best. And so that you wind up doing a lot of backtracking education and like proving the point of we can't, we don't know what we don't know until we go in and do the instrumental.
[00:28:27] Nicole: Mm hmm.
[00:28:28] Renee: So I think that's.
[00:28:30] Nicole: There was a leader, a study by I think leader there, the percentage of misdiagnosis of dysphagia was something like, it's a lot. Yeah, 30%. I don't want to I'm not exactly sure what it was, but it was a lot of misdiagnosis of dysphagia and missed aspiration based on bedside. So, definitely important to do these instrumentals.
[00:28:53] Nicole: And maybe you don't do an instrumental if the clinical evaluation, you know, does not demonstrate any signs or symptoms of dysphagia. So. You know, the voice is clear, maybe in the patient seems to be swallowing. Okay. And there's, you know, not a high risk of dysphagia based on their history or their medical diagnosis.
[00:29:15] Nicole: So maybe those at during patients who present like that, we would not do an instrumental swallow study. Do you want to do maybe some contraindications? Yeah,
[00:29:28] Renee: yeah, for sure. Yeah, that's a great point because I always go over that when we would do the because in the health systems that I work for, we had to do a a separate consent for FEES.
[00:29:39] Renee: And that varies from, you know, state to state and locale to locale, but we had this sort of global. Consent that people signed when they came into the hospital, and this was not something that was, it was a separate procedure. So that had to be, we had to go through the contraindications as part of the consent process.
[00:29:59] Renee: But yeah.
[00:30:01] Nicole: So there's, I mean, there's contraindications for any instrumental, which is just that the patient might not be medically stable enough to tolerate it, or they're not able to participate in it for cognitive reasons. That's more for a modified where they have to kind of sit in the chair. We can do with patients, you know, with dementia, even if they're not able to follow the instruction if we're only really looking to see did this patient aspirate or not.
[00:30:28] Nicole: The. SLP is clinical judgment. Also if we don't think, say that the instrumental assessment would change the management of the patient. So no matter what happens after the FEES or after the MBS, we're still going to do the same thing anyway, then you also wouldn't do an instrumental assessment. But for FEES some contraindications are if there's some kind of trauma to the nose, the nose was, you know, bleeding.
[00:30:59] Nicole: You wouldn't want to do a fuse in those cases patients who may be what else?
[00:31:09] Nicole: I'm trying to think at the top of my head for like
[00:31:12] Renee: deviated septum. You want to go on the other side and see if maybe you have a little, because sometimes with deviated septum, it's like the one side is almost completely blocked and the other one's like a wide open prayer. You could get in there all day long.
[00:31:25] Renee: But that's not always the case. Sometimes the you know, especially in the like really petite, I've seen some really petite older females who you couldn't, you couldn't have gotten the scope in there if you had been able to dilate their nose, it just wasn't going to work without some extreme duress, but
[00:31:44] Nicole: Maybe if they're moving a lot so severe disorders.
[00:31:48] Nicole: Yeah, the recent trauma and or severe agitation. They're just trying to rip out the scope. Yeah. Any traumas to the. Nasal cavity or like around the nasal cavity if they had like some kind of surgery or injury or a bilateral obstruction of the nasal passages. So, yeah, that's why you do kind of you look at one.
[00:32:13] Nicole: If you can't get in there, then you kind of try to go into the other nasal cavity.
[00:32:19] Renee: Yeah. And I will say I've scoped a lot of patients that had TBI, who were still probably like a Ranchos four who were able to do it because they wanted to eat. And it was like, if you explain that, hey, you know, this might be uncomfortable for you for a minute, but a lot of times those patients aren't as their sensation is diminished anyway.
[00:32:38] Renee: And so they don't even really feel it the way that some of our other patients who may be hypersensitive to the presence of the scope. And then the other thing was, you know, the, if someone who has a chronic nosebleed, of course, you don't want to go up and risk hitting anything that could potentially cause that nosebleed to happen.
[00:33:01] Renee: I'm trying to think of, there was, there was one more I mentioned and I, I think you hit it though. Trauma, agitation, and there's been times when, you know, I thought it was like a, a sure shot. It was going to work out fine. And there was, I couldn't, there was no way. Sedation is the, as another one, it's I've gotten consulted before for patients who were still pretty heavily sedated in ICU where you, you know, you, I mean, it's just not safe.
[00:33:29] Renee: You don't want to give them anything when they're not able to be. Mostly awake. Breathing is more important than swallowing at that point. And if you can't get them to wake up, we don't want to be throwing something into their oral cavity that's going to go. Their pharynx is going to go who knows where if they're not awake and can't swallow it.
[00:33:48] Renee: So, just making sure that you're looking at all those pieces because FEES now I think is, is pretty across the board in different settings. So it's important to know that.
[00:33:59] Nicole: Yeah, for sure. So, yeah, we kind of went over the indications and contraindications for why you would do a FEES. And like, you would also refer not only, you know, to see if there's aspiration or penetration or residue, you would want to refer, you know, to Why this patient having the trouble with their swallowing so we can determine is it a delay?
[00:34:23] Nicole: Is there premature spillage? Is it because there's poor laryngeal vestibule closure or some kind of anatomical reason and knowing, you know why the patient's having trouble swallowing from there, then we can develop an individualized treatment program. So, that would be obviously another reason why you would refer us to kind of get a really.
[00:34:46] Nicole: Individualized treatment program. Yeah, and compensatory strategies that we can do because you can't trial, you know, a chin tuck unless you are using an instrumental study because sometimes a chin tuck can actually increase the patient's risk of aspiration.
[00:35:05] Renee: Yeah. And depending on, like you said, the diagnosis I've had you know, even though it was modified barium, but even with FEES, I've had some interesting patients who were like, their diagnosis wasn't a stroke or TBI or ALS or Parkinson's or anything like that.
[00:35:21] Renee: I had a couple of people that had intellectual disabilities who also had seizure disorders who were on medications for seizures and were eating had been placed on at their like group home or their facility that they lived at pureed within. And I had actually three different people within like a six month period who all aspirated only the pureed.
[00:35:46] Renee: And it was like the weirdest thing because they just, I think the text increased texture was better for them. And the physician that I was working with at the time kind of related it or connected it back to some of the anti seizure medications and that the sensation changes that kind of co occurred from the medication and in the presence of them having had seizures for a good long spell of their life had made the sensation changes in that musculature so that they thought Pureed was the safest.
[00:36:20] Renee: And then in all actuality, it wasn't, they could eat a regular diet, just fine. And the pureed was the trigger. And it was like a copious amount of like, you know, you're talking someone who doesn't necessarily have the best impulse control. And sometimes with instrumentals, we want to see that because we want to see what happens when we're not there.
[00:36:37] Renee: And so they would take these giant scoops of pudding and the giant scoop of pudding is now aspirated. And I'm like, whoa, That's not what I thought was going to happen. So, again, I think just familiarizing yourself cause the, the diagnosis can really vary in the medications that people take can really interact too.
[00:36:58] Renee: And so having the knowledge of what was happening prior to this new diagnosis is really important. Cause it's always like a little puzzle. Right. Like putting together. Oh, wow. They did this. And I wasn't expecting that based on the where the stroke occurred. I wasn't expecting that. But then you come to find out they have something else going on.
[00:37:18] Renee: That was pre morbid to the stroke, which makes total sense.
[00:37:22] Nicole: Yeah, thicker viscosity is definitely not always better. And we find that a lot with the liquids where patients are put on honey thick or nectar thick and actually due to the residue, they might be. Aspirating that, and then the thin liquids.
[00:37:40] Nicole: Maybe the patient's coughing here and there occasionally, but they're actually swallowing that safer and clearing the material from the airway. So that the thinner liquids might be better.
[00:37:53] Renee: Yeah. So what are some recommendations for ways that you can gain more competency? Because I think, and I, you know, I just think back to like my FEES training when I was, I was a CF and I went to, And I had a wonderful experience.
[00:38:11] Renee: So I had Beth Cormell out in Raleigh. I did my FEES training with her, but you know, we did the standard 25 observations, which were normals and abnormals, and then went to the course. And, you know, even after I went to the course and I had done several passes, I still had a lot of work to do to get to where I felt like I was, I won't even say competent, maybe not even the best word, competent enough.
[00:38:41] Renee: But it certainly gets better. Like the more I learned and the more I did it and the more that I sought out education. So what, what are some suggestions or recommendation for areas of competency that you would, you would recommend?
[00:38:56] Nicole: It's a good question. Cause we as speech pathologists really need to be competent in every aspect of care that we provide to our patients.
[00:39:03] Nicole: I mean, that's also, if you're, As C's, you know, have your C's, then ethically, we're obligated to kind of make sure that we're trained and competent in providing these services to the patient. So that includes FEES, and FEES is a competency, it's not a certification, so there's no special certification from ASHA or any other body.
[00:39:26] Nicole: There's no oversight from ASHA. We just need to get our training and competence. And we can perform this procedure independently. So some of the ways that we can do that attend, you know, first step, I guess, would be to attend an ASHA approved CE course. Traditionally, this is, So Susan Langmore wrote a very, like, great article on ASHA competency, so I'm kind of pulling a lot of this information from that.
[00:39:57] Nicole: She indicates that traditionally it's 12 full hours, completed in two full days, and includes at least four hours of hands on practice. And then take and complete an exam based on those components of the course, would be step two. Step three would be. Handling the scope on healthy volunteers. So this is where the numbers kind of gets into it.
[00:40:22] Nicole: But there are some states that have certain numbers that it's necessary to obtain, but not all states. So I know New Jersey, for example, it's 25. New York does not have any number. So that could mean you're competent after 10. That can mean you're competent after 50, but. Usually the more scopes or passes that you're getting, the more competent you'll be.
[00:40:45] Nicole: You do want to though check your state requirement.
[00:40:48] Nicole: You should get at least 10, I would say, before you're competent. And that's the number that Suzanne Langmore listed. But again, the number can vary from person to person. You want to document how many procedures you've performed on both normals or patients without dysphagia.
[00:41:07] Nicole: And then sometimes you'll use like simulation training devices. So some of these courses will have like a head model or mannequin as the first step before going into your normal passes. I keep putting that in air quotes because sometimes even when we do. the passes on volunteers, you might get some reflux or anatomy changes as well.
[00:41:33] Nicole: So this kind of helps a clinician to get a sense of what is normal because you need to know, you know, what's normal to know what's disordered. So get at least 10 passes on healthy volunteers with no dysphagia. Then after that, and usually again, your ASHA course should have those passes with it. But you can get them in other ways.
[00:41:55] Nicole: Like maybe someone at your facility will just kind of volunteer to be scoped, so a nurse or, you know, a CNA or something like that After that, step four would be to pass the scope and perform FEES on patients. So again, there's certain states that have a certain number for that. And you know, different people can be competent after a different number of procedures.
[00:42:23] Nicole: Susan Langmore uses 15 as the minimum should be performed under the direct supervision of a competent speech pathologist or physician. So for your first passes on patients. And then after that, step five would be a mentoring. So having someone kind of to be able to, you know, ask questions to to kind of maybe review your, your FEES, exams, and make sure that you're writing them accurately.
[00:42:53] Nicole: They might sign off on a competency assessment. So ASHA actually has a dysphagia competency forum on their website. That kind of goes through the different, you know, areas of competency. So I can kind of talk about that a little bit. It would be knowledge of like normal and normal and disordered swallowing.
[00:43:15] Nicole: So in terms of like the anatomy and physiology throughout the lifespan indications and contraindications of the FEES procedure, patient assessment elements of a comprehensive FEES. So maybe like your protocol and how to go about, you know, your exam in terms of looking at your, your laryngeal findings, looking at pre swallow tasks.
[00:43:43] Nicole: So vocal fold closure and posterior pharyngeal wall motion. So those kinds of things. Are involved in a comprehensive exam secretion management ability to managed their secretions and then the bullish trials how you're able to manage the actual equipment. Are you able to pass the scope adequately?
[00:44:05] Nicole: Are you able to manipulate the scope the right way? Maintain it, disinfect the equipment. So that's really important for infection control. Sometimes using topical anesthetic when appropriate in certain conditions manipulating the endoscope for the best position. So making sure you're getting a good view of the patient's whole anatomy and maybe even so there's two different views of the top of the airway and also going a little bit closer to make sure that nothing passes into the vocal cords and into the airway.
[00:44:40] Nicole: And a good view so that you're minimizing discomfort as well, and being able to direct the patient with a pro, you know, like, what should we do next now that the patient maybe did aspirate the thin liquids, what can we try to prevent that from happening, so what kind of maneuvers can we can we try with this patient.
[00:45:01] Nicole: And then after your, you have your mentoring, so that's step five. Then you might have like indirect supervision after that. So that's where you might ask your mentor, just like, you know, questions that come up periodically about specific patients that you might have difficult. And maybe it's remote where I always comply with like HIPAA regulations, but maybe that's done remotely where you send videos and they can kind of review those.
[00:45:30] Nicole: So those are the six I'd say steps for, for mentoring and for competency.
[00:45:38] Renee: Yeah. And I think it's important to note now too, there's there was also advanced FEES courses that I think when I first started, I don't remember there necessarily, there might've been one now there's a lot, or there are like refresher courses for people who may be.
[00:45:52] Renee: Not, not necessarily change practice settings, but maybe you went to a job where they didn't have a FEES program and you helped start it and now you haven't done it for a little bit of time and you want to make sure that you're competent and that your, your skill set is still up to speed because the passing of the scope is a skill that's separate from practice.
[00:46:11] Renee: The the other pieces of what we're looking at. And I think that was one of the harder things for me to describe to people that came into the health system who were not FEES competent prior to and they're not done any training because they're like, Oh, how hard can it be? And I'm like, okay, depends on the person you're scoping.
[00:46:29] Renee: Sometimes it's a little bit can be a real big challenge. So you have to be mindful of that. I know in Virginia where I'm at, we're not allowed to do any kind of topical anesthetics because that's considered medication. So that's one of those things too. You want to make sure that you're aware of what your state or locale requires or denies you being able to do.
[00:46:52] Renee: But one of the really cool things about being at the FEES course that I was at 400 years ago, we had a, an opera singer as one of our SLPs in the course. And so when we scoped her, she had a vocal fold hemorrhage. So again, we weren't able to say it like that, but our instructors were like, Oh, wow.
[00:47:14] Renee: And described it and, you know, sort of talked us through, this is what it is, but don't call it that. And then when I went back to the inpatient rehab we had a dietitian who, she described it as a Minnie Mouse voice. She always said she had a Minnie Mouse voice. That was how she described it, not how we described it.
[00:47:33] Renee: So she volunteered for scoping when I was going through my competency training. And she had had, A virus that caused her to have true vocal fold paralysis. And so she actually had a prosthetic on her vocal cord that kept her closer to midline on the one side. And so that was really cool because she didn't have dysphagia, but like if I had, if she hadn't volunteered, cause she thought it would be cool to see what it looked like herself.
[00:48:02] Renee: We wouldn't have had that experience. So you do get some kind of like really interesting. Volunteers, he'll just be like, yeah, this weird thing. Well, want to take a look at it? And I'm like, yeah, sure. And you look and you're like, what, you know, the competency can, it sounds daunting, but a lot of it can be such a great learning experience too.
[00:48:23] Renee: And I think, you know, being a CF when I did it, I was already so like nervous about literally everything I did, breathing, waking up in the morning. It was a lot of pressure and a lot of a challenge. But it was so cool to be able to have that experience that early on and see all those things. So yeah, I think it's the competency part can be really interesting and really fun.
[00:48:48] Renee: I think looking back at it is probably a lot more fun in my own mind now than there probably was at the time because there was a, yeah, now there's like, okay, no big deal. But I think the same speaks to tracheostomies because again, I was with someone as my clinical instructor as a student who had tracheostomy patients.
[00:49:11] Renee: And so I started out as a student. learning about trachs and just starting in the very basics of learning the parts. And this, it's a little bit different now because there's so many more manufacturers, they've changed a lot of the mechanics of the trach as far as the pieces and the parts now.
[00:49:30] Renee: Some of the things that make it extended or some of the things that maybe have been a little less commonly used depending on where you're at. Like the the permanent, more permanent cannulas, you see a lot more of the disposable or the removable ones. But, you know, that's another area that I think kind of ties in a little bit with our our competencies and talking about like just recommendations for how do you even see.
[00:49:55] Renee: start with tracheostomy because a lot of times what I've seen in the, especially in the acute care world is managers get really desperate for help, especially weekend coverage and stuff like that. And so they're like, Oh yeah, Sally Sue came from 25 years in the school system and not that there's anything wrong with that, but it's a big change.
[00:50:13] Renee: Just like, I don't feel like I would be good at. Going into a classroom that was maybe a a self contained classroom and, and working with kids with autism. That's just not, I'm not, I don't feel like I would be effective or competent in doing that. So I think the flip side is there. How would we start with competencies for looking at trachs and getting that education and that competency that we need.
[00:50:40] Nicole: Right. Cause that population patients with tracheostomy are at such high risk of preventable adverse events. So, and yeah, safety is a big issue with patients with tracheostomy and speech pathologists are having a more and more important role with this patient population. And we can do so much in terms of improving their quality of life and even improving patient safety as well.
[00:51:11] Nicole: Cause Our role can include, you know, communication management, so getting them assistive devices or AAC getting them speaking valves or talking trach tubes, so all those things we need to also be confident in. We can't just say, I've never seen this speaking valve before, let's see kind of what happens and put that on a patient because if you don't deflate the cuff, Yes, to me, then the patient can actually not be able to breathe and could die.
[00:51:46] Nicole: So we really need to be competent in this area. So communication, swallowing management, patients are at such high risk of aspiration. There's crazy statistics, like up to 80. 6 percent aspirate and of those, it's over 50 percent or silent aspiration. So you're not coughing or choking at bedside and these food coloring modified Evans blue dye tests that some clinicians provide food and liquid dyed blue or green.
[00:52:17] Nicole: Those tests are not sensitive. So, you know, You give them food with blue food coloring, you suction them, and you get blue, that means they aspirate it, but if you don't get blue, that could mean they're still aspirating, you just didn't suction the right spot to be able to remove that material. So we really need to be careful with this population.
[00:52:40] Nicole: Also, with decannulation, we're having more and more in a role with that as well. So, secretion management, cough strength, swallowing, and the use of FEES to determine if these patients are candidates for decannulation from our perspective. I mean, we're not the ones that are like, Yeah, now that I say that the patient, the trach removed, it's always the physician who at the end of the day has the you know, writes the order for removal of the trach, but we have such a big role.
[00:53:09] Nicole: So competencies in those types of things, the first step might be webinars online. So, tracheostomy education has a lot of webinars past the same year where you're viewing these webinars on so tracheo education has swallowing management verbal communication strategies where it goes through different types of speaking valves and talking trachs and how to You know, provide those to your patients safely trach care webinars and trach teams to get your facility kind of all on the same page.
[00:53:48] Nicole: Trach teams are kind of a really great multidisciplinary way to keep track of everyone and make sure everyone, I'm going off, but Off target. But anyway, so the first step would be webinars. Second step might be to get some hands on training, maybe use some simulation devices, so a mannequin that kind of appears like, a person you're, you're getting training in suctioning, you're getting training in deflating the cuff, placing a speaking valve.
[00:54:20] Nicole: You can also, yeah, those are the main things talking trach tubes. You can kind of do that on a, on a mannequin as well. Have a ventilator. We actually have an in person tracheostomy course coming up in June 22nd in New York. So those kinds of things are, are great to to go to some kind of hands on training.
[00:54:42] Nicole: And then the third step. Definitely like in your facility, having someone that already, you know, sees trach patients and they can kind of, or getting someone from the outside to come in, to train you on the patients and actually going and suctioning the patient and, you know, In each state has different laws about suctioning too for speech pathologist.
[00:55:05] Nicole: We are able to do it in New York. And then your facility also needs to say, yes, you can do it. So having like protocols for all of those things that we talked about, and then also having a competency where, you know, each step someone signs off, yes, they can deflate the cuff. Yes. They're able to suction.
[00:55:22] Nicole: Yes. They're able to place the speaking valve. So those would probably be, The, the steps to competency. And trach education does have some papers that kind of show what exactly kind of what I went through, but how to become competent in those areas.
[00:55:44] Renee: Yeah. Again, when I was in inpatient rehab, we had an LTAC floor.
[00:55:49] Renee: And so we got to do respiratory rounds with the respiratory therapist and the pulmonologist. So that was a great way to get hands on training so that you didn't necessarily have to be the person that was doing the things, but you could go in and observe the things and listen to the rounds of what this patient's case history looked like, what had been done respiratory wise learn about ventilator settings, learn about.
[00:56:15] Renee: The trach stuff and like how be, you know, downsizing and when that was done. And there was a lot, there's just a lot to learn. And I think even having that part, if you're not the one going in, like in Virginia, we can't suction, we can suction outside of the cannula, but we cannot go down inside. So we can't do that.
[00:56:35] Renee: That's a respiratory therapy thing. And so, but being in the room and seeing it done and being like more comfortable seeing it, cause some people it's just not their thing. And then other people, like, I don't, I don't want to see, sorry, this is going to be weird, but I don't want to see poop. But if you want to get.
[00:56:54] Renee: Or if they throw up and I got to like suction them when I'm, you know, in there, I don't care. That doesn't bother me. I guess I'm weird. Like, I think that that's that's another space where you just, you kind of get a little bit more comfortable with that. I'm seeing that we're getting a few questions here.
[00:57:14] Renee: So if you're okay with kind of moving into that realm, Nicole, does you want to add anything? Okay. So someone said, Alyssa said, do you feel that MBS IMP is adequate training? I think, I mean, I can answer, or we can both answer. So if you're talking about FEES, then no, cause that's modified barium swallow training.
[00:57:33] Renee: But when it comes to modified barium swallow training, I would say that that's I mean, I'm not going to endorse it as far as I don't get paid by them or anything like that, but I do think it's good. Training. I know a lot of the students in our dysphagia program at our university do the MBS IMP student training.
[00:57:52] Nicole: Yeah. I also think it's great just for norm knowing part of what you need to know for feeds is normal and I'm swallowing. So just, it does go through that pretty very well.
[00:58:04] Renee: Yeah. I think the anatomy, yep.
[00:58:06] Nicole: That underlying knowledge and then go to like a basic FEES course. So they have a lot of FEES courses throughout the country to, to help train yourself in FEES.
[00:58:19] Nicole: We have some on the site that are listed on endoscopy dysphagia specialists. If you wanted to look at that, like different places where you can get basic FEES trained and What's that?
[00:58:33] Renee: Oh, I was just going to say, I don't want to go out of order, but that this one's more related to what you just said.
[00:58:38] Renee: So someone said is the website for trach webinars, tracheeducation. com.
[00:58:43] Nicole: Oh, it's called tracheostomyeducation. com. T R A C H E O S T O M Y. education. com.
[00:58:51] Renee: I and then someone else said, hold on, I gotta go back here. What's the difference between nasoendoscopy and FEES?
[00:59:01] Nicole: So nasoendoscopy is when you, is the placement of the nasoendoscope into the nares.
[00:59:10] Nicole: It's, Like, we use a nasoendoscope for FEES. Nasoendoscopy would be more of a procedure that an ENT would perform to check the nasal passages for You know, I need anatomical deficits in the nose.
[00:59:30] Renee: And then the other question is, is FEES training just on adults or peds too?
[00:59:36] Nicole: You would have, most of the FEES courses that I know of are adults.
[00:59:41] Nicole: They do have some pediatric FEES training and it's usually all about pediatric FEES. So it's usually a separate training because for me as an adult FEES specialist, I would, I can't even touch a little peed. It's totally different anatomy, physiology. So yeah, you would need two separate courses to be competent in both areas if you wanted to do both adults and peeds.
[01:00:07] Renee: Yeah, I agree because that people are like, Oh, you could do Pete's feeding. And I'm like, it's, it's different than what I do adapt. I'm not scared of children. I have children. Like it would scare me to think I've got this little tiny person. And I think that, again, that's one of those things. That's definitely a personal preference.
[01:00:26] Renee: And I think if you felt like you wanted to get trained on both, it's certainly. Yeah, sure. You could, but I know my FEES training and the ones that we've sent our. staff to throughout the years have all been for adult medical based, but all excellent questions. Where can one train for peds?
[01:00:45] Renee: I personally have no idea. That would be a good question for like feeding matters may know the feeding matters. I think it's. org website. They have questions like question and the answers are people that you can email. In the pediatric feeding disorders world, I think that would be a great way to find out because I have never personally seen just a a one training for peds for FEES.
[01:01:14] Nicole: I see one in Texas. It's the facet. org. I don't know anything about it, though. I just.
[01:01:24] Renee: But Nicole, thank you so much for joining us. This was really helpful and I appreciate you being so proactive and, you know, answering the questions and having everything prepared. It's just, it's always good to speak to somebody who comes on and has such a good wealth of knowledge to share. Thanks again, Nicole. I look forward to seeing you again.
[01:01:46] Nicole: Thank you.
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[00:00:00] Renee: Welcome to Brainstorms Functional Neuro Rehab for SLPs presented by SpeechTherapyPD. com. This podcast is designed for the adult medical speech language pathologist. Most of our audience members work in settings such as acute care hospitals, private practice, Outpatient hospital clinics and inpatient rehabilitation hospitals.
[00:00:28] Renee: Each episode has an accompanying audio course on speechtherapypd. com and is available for 0. 1 ASHA CEUs.
[00:00:42] Renee: The content of this course is based on the research and experience of The presenters. Presenters, the listener, is responsible for researching to determine if the information and skills taught are appropriate for their client, students, or patients. Speech therapy pd.com does not necessarily endorse, recommend, or favor the information shared nor any of the claims, opinions, statements, offers or services made by the presenter.
[00:01:06] Renee: Hello and welcome everyone. My name is Renee Garrett and I am your Speech Therapy PD. com podcast host for Brainstorms Functional Neuro Rehab for SLPs. Before we get started, we have a few items to alert you to. Each episode is 60 minutes and will be offered for 0. 1 ASHA CEU. Here are the financial and non financial disclosures. Nicole DePalma is the owner of Endoscopy Dysphagia Specialists. She is also a Passy Muir consultant and the president of Tracheostomy Education. Nicole DePalma receives an honorarium for her participation in this podcast from speechtherapypd.
[00:01:47] Renee: com. She has no relevant non financial relationships to disclose. My financial disclosure is that I'm a paid employee of a private consulting firm in the Commonwealth of Virginia. I'm also an adjunct instructor for both James Madison University and Old Dominion University. As the host of Brainstorms, Functional Neural Rehab for SLPs, and other webinars on speechtherapypd. com,
[00:02:13] Renee: I do receive financial reimbursement. My non financial disclosure is that I'm the secretary for the Communication Disorders Foundation of Virginia. Questions can be written in the chat box or the Q& A and will be answered at the end of the presentation. Now, without further ado, we welcome our guest, Nicole DePalma, MS, CCC, SLP, who is the owner of Endoscopy Dysphagia Specialist.
[00:02:40] Renee: She received her bachelor's degree at Georgetown University and her master's degree at New York Medical College in Speech Language Pathology. She has over 15 years experience of 15 years of clinical experience working with patients with dysphagia, including the medically complex, such as those, those with tracheostomy and mechanical ventilation.
[00:03:03] Renee: Nicole provides competency training for SLPs. interested in FEES. She also provides tracheostomy consulting for developing and implementing new protocols and performance improvement strategies and providing comprehensive education to clinical staff. Before endoscopy to stage a specialist, she was the director of clinical education at PASI mirror incorporated.
[00:03:27] Renee: She has also worked previously as director of speech language pathology at Barlow respiratory hospital and research center in Los Angeles, California. Nicole is president of Tracheostomy Education, providing in person and remote courses for universities and facilities nationwide. Welcome, Nicole. So nice to see you.
[00:03:49] Nicole: So much for having me. I'm so excited for this presentation.
[00:03:56] Renee: Oh, good. Good. Well, welcome. I think we've crossed paths a couple of times, but never actually met. So, thank you for, you know, reaching out and agreeing to be a part of this, because I think it's really important to talk about what we're going to talk about tonight.
[00:04:11] Renee: I think so many SLPs and even audiologists have moved into this realm of trying to figure out how to have their own business, whether it's like a side gig or a full time thing or start out as sort of like a more of a virtual or like almost like a version of home health versus having a brick and mortar.
[00:04:31] Renee: So I think it's, it's interesting to have this conversation. So can, You talk to us a little bit just about why you started the mobile FEES business.
[00:04:41] Nicole: Yeah, sure. So FEES. for anyone that doesn't know, stands for Flexible Endoscopic Evaluation of Swallowing. It's a procedure where a small scope is placed in the nose, looks down the throat to check, you know, to make sure a patient is swallowing safely.
[00:04:57] Nicole: So kind of as a bird's eye view of the upper airway. So I started that business because there was kind of a need for fast. Reliable instrumental swallow studies. So I was working in a skilled nursing facility, and we noticed that there was just, it took a lot of time to get instrumentals for the patients, and sometimes weeks, months, sometimes we never, they never even got scheduled, because you had to rely on.
[00:05:22] Nicole: Nursing to schedule them. Often once they did go out for those swallow studies, we never got the reports back for whatever reason, or we'd have to chase them down. So those were all very, you know, difficult to provide good patient care for the patients at those nursing facilities. So, and also with modified barium swallow studies, those you know, you have to again, transport the patient out to the hospital that can be even costly for the facility that patients out of the nursing facility for a long time.
[00:05:56] Nicole: So they miss their therapy. So, yeah, so I started mobile FEES so that patients can have a little bit better access quicker and, be able to spend, you know, a lot of time with the patient and with the treating clinician because that's missed too. When you send a patient out for a modified is it's just kind of that one clinician.
[00:06:15] Nicole: They might get some information, but when you have FEES, you typically, this is what we try to do or what I like to have is, For the treating SLP to come with me and make sure that, , they provide all the information about what's going on with the parent patient. And they also are involved in like, Hey, let's try this compensatory strategy that might work to help, you know, reduce any.
[00:06:41] Nicole: aspiration or residue or whatever it is that the patient that's going on with the patient. So, yeah.
[00:06:49] Renee: Yeah. It's always interesting because I've been on both sides of the, well, I've been on really, I would say three sides of the coin, even though there's not three sides because I started an inpatient rehab and LTAC.
[00:07:01] Renee: So we had access to FEES within our building. So, there were four three SLPs on our team that were full time and one part time. So we all were FEES. competency trained and perform them every day. So I had immediate access. And if we had the need for a modified barium swallow, even from our facility, we had to transport them to our we called it the mothership, our, our main hospital that wasn't the inpatient rehab facility which, you know, again, could be costly and just time consuming and a burden on the patient.
[00:07:34] Renee: Their family, I had to be, if it was my patient, I had to be the one to go to physically to the hospital. So there's a lot of barriers in that setting. if you don't have modified barium in house. And I know we're talking about FEES, but I just kind of wanted to piggyback off of what you said because even in acute care where I primarily did modify bariums every day we did have outpatient appointment slots.
[00:07:56] Renee: And so a lot of times what would happen is we would get people sometimes who would come on to Our schedule who, again, like you mentioned a snapshot in time. And so when I think when I first started in acute care, I was like, Oh my gosh, they're aspirating. Whoa, we got to change the diet immediately. And then I started as I grew as a clinician and had more experience, I started realizing that I don't need to be the one to make that final call.
[00:08:22] Renee: I need to be the one to say, this is what I saw. This was a physiological problem and make sure. Because a lot of the time, the people that were sending outpatients over to me were people that I knew or people that I had had reached out or I had reached out to them because of their patient. And so we had this rapport, which I realize is not the case for every.
[00:08:42] Renee: Facility. Cause we, you know, we had skilled nursing facilities. We had home health folks, SLPs who sometimes would come, which I was always happy because again, I've got like, you know, what, 10, 15 minutes max with this patient, I don't know anything about them other than what I've read in their chart, if I'm lucky that someone sent a piece of paper that said X, Y, Z about what they'd been working on and then an outpatient.
[00:09:06] Renee: It was funny. Cause I worked for the same health system. But our outpatients had to go through the acute care setting. And so I found it funny that some of the people that were still in acute care would make these decisions about the patients I had been working with for four weeks or six weeks or whatever.
[00:09:24] Renee: So it is kind of a really interesting space that you find yourself in as you've moved from, you know, moved to different settings and then, you know, for some, like we had FEES in acute care, but we didn't do them as outpatient. Yeah. So, like you mentioned, it is, it's a huge need and a lot of the skilled nursing facilities here locally in the east coast of Virginia, we, a lot of them have moved to doing contract based FEES, like a mobile FEES.
[00:09:52] Renee: Because it is quicker. It's more accessible. It had, you know, you have the person on site. So you've got the treating SLP there. So, I just kind of wanted to make that roundabout connection because there's a lot of pieces.
[00:10:06] Nicole: I was just gonna say, yeah, and like, I'm not gonna say that these is better than the modified sometimes we use both right because Always, you know, there's different indications for both procedures that some, you know, there's some ideal patients for FEES versus more ideal patients for modified.
[00:10:29] Nicole: So sometimes even, you know, you might do the FEES and say, Oh, well, actually, it looks like it's a little bit more of a. You know, a UES or whatever
[00:10:40] Renee: we need to see the oral phase a little bit better.
[00:10:43] Nicole: Yeah.
[00:10:46] Renee: Yeah, it is. It is interesting though because I think it speaks to, you know, kind of not just your network but your communication where the communication experts that we need to be making sure that we're closing those loops on either end.
[00:11:02] Renee: And so I think, you know, being in person certainly helps that because then if you were to maybe be at another facility and someone has a question, they know how to reach out to you to get the answers because it is, it's, it's a challenge. I don't feel like it, it should be in this day and age with all this electronic access that we have, but it remains to be quite the challenge and scheduling is quite a challenge.
[00:11:26] Renee: I know when I was the only SLP in acute care for a little bit before they finally hired someone I only had four outpatient appointments a week. So you can imagine we were scheduling out three months, four months sometimes. And then during the pandemic, we weren't doing them at all for a little bit of time.
[00:11:44] Renee: So. Again you know, it didn't need, we can't cease the instrumental because of all these other variables. So I think that that's a really important part. So what would you say some of the benefits other than what we already kind of just touched on what are some of the benefits to the mobile FEES, other than just, you know, the time, the time turnaround being quicker and the, the access being a little bit better.
[00:12:11] Nicole: Yeah, yeah, like you said we did talk about a lot of that I guess. To further the point about the ease, though there are some patients you just can't even transport, right, especially where it's really difficult, or they have all these tubes connected to them, so that makes, you know, transportation difficult, or you know, you can do longer studies with these, so there's, there's radiation with the modified barium swallow so patients who have fatigue issues might fare better with a fee so that we could do maybe a whole meal to see if, you know, they're fatiguing at the end of the meal and that's causing issues.
[00:12:50] Nicole: And also the fluoroscopy machine kind of turns off in between swallows so you can kind of see the whole entire process. Other benefits we can kind of directly view the anatomy of the patient. So we can view vocal fold mobility. We can view the pharyngeal mucosa if there's any swelling that's attributing to the patient's dysphagia, if there's bulging at the posterior pharyngeal wall, or maybe there's even like masses.
[00:13:19] Nicole: I mean, we don't diagnose what, whether the patient has some kind of cancer, but we could, you know, see if there's anything, then refer, you know, to the correct specialist, to an ENT maybe. But viewing that anatomy enables us to really be able to, you know, maybe get a better treatment for that patient. So is the, does the patient have a vocal fold paresis or paralysis?
[00:13:45] Nicole: And then, you know, you know, maybe we have to do some sort of head turn or something to help compensate. We can also view secretions, which you know, if a patient has a severe dysphagia, we might not even provide food or liquid to that patient, but just viewing those secretions is really important for us to be able to, you know, help that patient with their, with the management, especially if they have a trach viewing secretions, you know, helps us determine if the patient can get decannulated or get their trach removed.
[00:14:20] Nicole: So we want to know, are they managing their secretions? Can they cough those secretions out? So those are all really important things that we could, , really assess with FEES. Other benefits might be again, like that the treating SLP is with us so that she can say, Hey, , during the bedside, though, actually, this is what was happening with the patient.
[00:14:41] Nicole: And that's, we haven't seen that yet during the FEES study. So maybe we continue doing try. Maybe they were coughing on liquids and we haven't seen that. So we continue to provide it until we can kind of mimic what the speech pathologist is seeing. So that she can, you know, know, okay, maybe the cloth is just due to
[00:15:01] Nicole: penetration not aspiration and they're clearing that from the airway. So we know that information. Based on what's happening at bedside. And again, they can tell us about any compensatory strategy that they think might be beneficial. And the patient can also view the, the actual swallow study. So either during the swallow study, we can do some biofeedback and like show them the monitor and say, Hey, You know, you have some material in the air in, in your throat or whatnot.
[00:15:36] Nicole: Some can you try to clear that material and they can use strategies like a hard swallow and see if that works and whatever they can do to kind of help clear that material. So that's, I think, a really great, one of the best things about FEES is that biofeedback tool. And then, yeah, like the turnaround usually for us, like one to three days from consultation.
[00:16:02] Nicole: So instead of waiting those weeks or months, kind of get in there pretty quick, more cost barium swallow. And some studies show that it's more sensitive to Aspiration. And viewing the residue then modified barium swallow. So I think those, I think I hit most of the points.
[00:16:23] Renee: Yeah, no, I think that's excellent.
[00:16:26] Renee: And I, you know, it's funny cause you mentioned the biofeedback and I, the one thing that always got a lot of, you know, especially with our patients with TBI and stroke was that I'd say, Hey, you have a lot of residue. Can you do a really hard swallow? They go, no, I don't. I'm like, well, you have some stuff hanging around your throat.
[00:16:43] Renee: I can see it on the screen. Can you swallow? No, I don't turn the camera or turn the screen. And they'd be like, Oh my God, is that me? Can you swallow? That's like the best thing ever. When patients are like, no, I don't, I don't feel anything. And I'm like, Well, that's great, but I can see it. So can you swallow And they wanna have a conversation about how they're not gonna swallow until until they see it, and then they're like, oh, okay, this makes sense.
[00:17:13] Renee: Or the number one was always you know, when you go and, and you explain what you're gonna be doing and that you're gonna put this tiny camera. Up their nose and they go, oh my gosh, that's gonna hurt. And I'm like, no, it's not too bad. If a person is doing it does it correctly, as long as you don't have anything, you know, anatomically, that's, that's structurally gonna be a barrier.
[00:17:35] Renee: And most of the time I'd get the. Oh, that wasn't nearly as bad as I thought it was going to be.
[00:17:40] Nicole: Right. Exactly.
[00:17:41] Renee: That's one of those things where I think I always laugh because I'm like, if I had heard, if I had had a dollar every time I heard that I could retire by now. But I think one of the important points you made too was about the pharyngeal mucosa because I had a TBI patient that it really speaks to oral care.
[00:18:01] Renee: And it's something that I try to share with my students. That. You know, if the oral care hasn't been performed on someone who's been intubated or even extubated in their mouth breather that bacteria and that fungal growth and that overgrowth of yeast can really progress quickly. And so, I had.
[00:18:20] Renee: gotten in with the scope and I looked and I was like, holy, what in the world? It looked like a cavern somewhere in a mountain. The thrush was so bad. And like you mentioned, we're not allowed to call it that because we can't diagnose it, but we can describe it. And that's another thing. I always try to tell students is that get good at knowing what those anatomical, not only the landmarks are, but being able to describe, with purpose what, not like a creative writing experiment, but describe with purpose what you saw.
[00:18:51] Renee: Was it, you know, something that was edematous or swollen? Was it something that looked atypical based on what you'd seen before? All those kinds of things. So, I thought those were really really important points that you made.
[00:19:06] Nicole: Yeah. And, and back to, yeah, the thrush and the secretions I've seen in there from patients who are MPO just these thick secretions sometimes if they're not getting anything at all.
[00:19:20] Nicole: And sometimes I've gone in there and I couldn't even see the airway like we're just covering everything. So yeah, you can kind of get a really good view of. Of all that, the anatomy, the secretion management, so really important to be able to go from there into, okay, what's the next step? A lot of times if you have like these thick secretions, you need to clear them out, so maybe ice chip trials to try to clear those secretions and get Yeah, a more normal airway or a cut.
[00:19:56] Renee: Yeah, and it's always fun too for the students to see and even like newer, you don't have to be a new clinician, but you can be newer to FEES and having that, seeing the anatomy from that, viewpoint, you see things like cobblestone. Sometimes you see some other like anatomical differences. Some people just, their retinoids are not symmetrical.
[00:20:18] Renee: They're just kind of sit funky. And that's, it's good to see those those, those variants, but then also to be able to see what normal swallowing looks like. And that was part of the, the competency. So, I know that's a question for, that we're going to talk about in a little bit, but What would you say is like the primary reason that an SLP should be referring for an instrumental whether it's a modified or a FEES?
[00:20:47] Nicole: Right. Really? There's not a
[00:20:48] Renee: primary. There's a whole bunch.
[00:20:50] Nicole: Yeah. I mean, I guess I would start with how we're assessing them right at bedside. We're assessing our patients. We're doing, you know, a good history, a cranial nerve evaluation. We're asking questions about how a patient swallowing. Are they having trouble?
[00:21:09] Nicole: And then we're providing food and liquid to these patients to some of these patients to determine if you know, they have a dysphagia. So we determine the behaviors associated with a swallow with swallowing function and observe the presence or absence of signs of dysphagia, including if they're fatiguing or.
[00:21:29] Nicole: And also like their posture and positioning as well. So in terms of referring. I wanted to just go into ASHA a little bit, because they indicate that during non instrumental assessment that may provide sufficient information for a clinician to diagnose oral dysphagia, right? However, aspiration and other physiological problems in the pharyngeal phase can be directly observed Only via instrumental assessment.
[00:22:01] Nicole: So meaning that, you know, we can assess, you know, if they're having trouble chewing the food, if there's residue or pocketing in the oral cavity, and we can diagnose that as an oral dysphagia. During the pharyngeal stage, since we can't see it, we can only suspect a pharyngeal dysphagia, so some signs might be that the patient is coughing or throat clearing when we're giving them food or liquid or telling us that they're feeling foods and liquids getting stuck in the throat those are some signs that the patient's having trouble or just, you know, recurrent aspiration pneumonia.
[00:22:40] Nicole: Maybe they're not even showing signs at bedside, but they have that history. So indications can include concerns regarding safety and efficiency that might contribute to nutritional compromise, pulmonary compromise. For airway safety the need to identify disordered swallow physiology to guide management, need to assist determination of a differential medical diagnosis related to the presence of dysphagia, any kind of medical condition or diagnosis associated with a high risk of dysphagia.
[00:23:14] Nicole: So something like stroke or MS, ALS, those types of things that might. Parkinson's disease. So those kinds of disorders might trigger you to think, okay, this patient could have some kind of pharyngeal dysphagia a previously identified dysphagia with suspected change in swallow function or the presence of a chronic degenerative condition.
[00:23:36] Nicole: So those are all your indications per ASHA for an instrumental. Swallow study. And I love quoting like this. There's this one study that was done that I think is so important because there are a lot of therapists still that you kind of, you know, a patient coughs on thin liquids. So we think, okay, let's just give them thickened liquid.
[00:23:58] Nicole: And if they're not, Waffling or anything, then that means they're safe to provide that nectar thick liquid. However, mild, the mild study showed that patients are at very high risk of. Silently aspirating the thickened liquid. So they're not coughing when we're providing the food and liquid up outside. But maybe they're coughing on the thin, but that could be a good thing that they're actually coughing on the thin liquids because maybe they're actually clearing their airway after giving them those liquids.
[00:24:32] Nicole: So, You know, changing the patient's diet based on a bedside can actually be detrimental sometimes to that patient because they're they could be silently aspirating that thickened liquid. So that's why it's really important to get an instrumental assessment and actually see what's going on in the throat because we can't, you know, see aspiration.
[00:24:55] Nicole: We can't see penetration. We don't know if that's happening. We don't know if there's residue in the throat unless we actually view the swallowing process. Yeah, I think those are the main reasons that we would do an instrumental swallow study.
[00:25:10] Renee: Yeah. And it's important, like you said, that the anatomical stuff too, because you know, you see things in the upper esophageal region to that, like strictures, you can see cricopharyngeal bars, you can see diverticulums and things like that, that would be a cause for referral.
[00:25:28] Renee: And again we can't always see that on a FEES, you can see it on a modified barium. But again, you know, we're looking at both sides of the coin. Because like you said, sometimes when I would do a FEES, there was an indication that I needed to look at something else. Maybe I didn't see what I thought I needed to see.
[00:25:47] Renee: And so we would recommend the modified for that reason. So I think, you know, having that That confidence in that competency, because confidence is one thing like I think would, especially when you, I think when you've gotten really good with the physiology, because it takes for me, I felt like it took some time.
[00:26:06] Renee: That wasn't something that I, we learned it sort of in graduate school in our graduate program, but it wasn't, It was more rote, right? It was like, if you see X, Y, Z, this, this, and this, and then when you see it in action with all these other deviations, it makes it really difficult for you to say with certainty until you've become more competent and more experienced and seeing things and taking courses.
[00:26:34] Renee: And I think when I did my dysphagia course in graduate school, we, we did. Like someone came and did a FEES demonstration with us where we just watched like one, and then we had 25 prerecorded modified barium swallows. That was like a quiz we had to do where we identified, like literally the only thing we identified was if it was normal, if they penetrated, if they aspirated.
[00:26:58] Renee: And that was it. So it's really important you know, to be able to look at. both instrumentals and see you know, if this is happening on the FEES, then maybe you need a different viewpoint. And the same thing happens with the modified. Maybe you need a FEES because what you're looking at here doesn't make any sense of the symptoms the patient's describing.
[00:27:22] Renee: But I do like that. You know, I think we're getting better at making making sure that we're, you know, Doing the best by the patient, meaning I always would describe it as I don't have x ray vision, so I can't see inside of your body. I can't see exactly what's happening. So this is the reason sort of the rationale in the starting point of the conversation about why.
[00:27:46] Renee: We would do an instrumental and why we need that. From a safety standpoint. But also sometimes when you're dealing with physicians or even nursing who, you know, they're both really important parts of our care team. But a lot of times if they've been educated in a certain way or, you know, They have experience where they've heard over and over that thickens better, thickens better, thickens better.
[00:28:08] Renee: Let's thicken everybody's liquids. Let's put them all on pureed. We don't really need to do an instrumental because pureed and nectar thick is the best. And so that you wind up doing a lot of backtracking education and like proving the point of we can't, we don't know what we don't know until we go in and do the instrumental.
[00:28:27] Nicole: Mm hmm.
[00:28:28] Renee: So I think that's.
[00:28:30] Nicole: There was a leader, a study by I think leader there, the percentage of misdiagnosis of dysphagia was something like, it's a lot. Yeah, 30%. I don't want to I'm not exactly sure what it was, but it was a lot of misdiagnosis of dysphagia and missed aspiration based on bedside. So, definitely important to do these instrumentals.
[00:28:53] Nicole: And maybe you don't do an instrumental if the clinical evaluation, you know, does not demonstrate any signs or symptoms of dysphagia. So. You know, the voice is clear, maybe in the patient seems to be swallowing. Okay. And there's, you know, not a high risk of dysphagia based on their history or their medical diagnosis.
[00:29:15] Nicole: So maybe those at during patients who present like that, we would not do an instrumental swallow study. Do you want to do maybe some contraindications? Yeah,
[00:29:28] Renee: yeah, for sure. Yeah, that's a great point because I always go over that when we would do the because in the health systems that I work for, we had to do a a separate consent for FEES.
[00:29:39] Renee: And that varies from, you know, state to state and locale to locale, but we had this sort of global. Consent that people signed when they came into the hospital, and this was not something that was, it was a separate procedure. So that had to be, we had to go through the contraindications as part of the consent process.
[00:29:59] Renee: But yeah.
[00:30:01] Nicole: So there's, I mean, there's contraindications for any instrumental, which is just that the patient might not be medically stable enough to tolerate it, or they're not able to participate in it for cognitive reasons. That's more for a modified where they have to kind of sit in the chair. We can do with patients, you know, with dementia, even if they're not able to follow the instruction if we're only really looking to see did this patient aspirate or not.
[00:30:28] Nicole: The. SLP is clinical judgment. Also if we don't think, say that the instrumental assessment would change the management of the patient. So no matter what happens after the FEES or after the MBS, we're still going to do the same thing anyway, then you also wouldn't do an instrumental assessment. But for FEES some contraindications are if there's some kind of trauma to the nose, the nose was, you know, bleeding.
[00:30:59] Nicole: You wouldn't want to do a fuse in those cases patients who may be what else?
[00:31:09] Nicole: I'm trying to think at the top of my head for like
[00:31:12] Renee: deviated septum. You want to go on the other side and see if maybe you have a little, because sometimes with deviated septum, it's like the one side is almost completely blocked and the other one's like a wide open prayer. You could get in there all day long.
[00:31:25] Renee: But that's not always the case. Sometimes the you know, especially in the like really petite, I've seen some really petite older females who you couldn't, you couldn't have gotten the scope in there if you had been able to dilate their nose, it just wasn't going to work without some extreme duress, but
[00:31:44] Nicole: Maybe if they're moving a lot so severe disorders.
[00:31:48] Nicole: Yeah, the recent trauma and or severe agitation. They're just trying to rip out the scope. Yeah. Any traumas to the. Nasal cavity or like around the nasal cavity if they had like some kind of surgery or injury or a bilateral obstruction of the nasal passages. So, yeah, that's why you do kind of you look at one.
[00:32:13] Nicole: If you can't get in there, then you kind of try to go into the other nasal cavity.
[00:32:19] Renee: Yeah. And I will say I've scoped a lot of patients that had TBI, who were still probably like a Ranchos four who were able to do it because they wanted to eat. And it was like, if you explain that, hey, you know, this might be uncomfortable for you for a minute, but a lot of times those patients aren't as their sensation is diminished anyway.
[00:32:38] Renee: And so they don't even really feel it the way that some of our other patients who may be hypersensitive to the presence of the scope. And then the other thing was, you know, the, if someone who has a chronic nosebleed, of course, you don't want to go up and risk hitting anything that could potentially cause that nosebleed to happen.
[00:33:01] Renee: I'm trying to think of, there was, there was one more I mentioned and I, I think you hit it though. Trauma, agitation, and there's been times when, you know, I thought it was like a, a sure shot. It was going to work out fine. And there was, I couldn't, there was no way. Sedation is the, as another one, it's I've gotten consulted before for patients who were still pretty heavily sedated in ICU where you, you know, you, I mean, it's just not safe.
[00:33:29] Renee: You don't want to give them anything when they're not able to be. Mostly awake. Breathing is more important than swallowing at that point. And if you can't get them to wake up, we don't want to be throwing something into their oral cavity that's going to go. Their pharynx is going to go who knows where if they're not awake and can't swallow it.
[00:33:48] Renee: So, just making sure that you're looking at all those pieces because FEES now I think is, is pretty across the board in different settings. So it's important to know that.
[00:33:59] Nicole: Yeah, for sure. So, yeah, we kind of went over the indications and contraindications for why you would do a FEES. And like, you would also refer not only, you know, to see if there's aspiration or penetration or residue, you would want to refer, you know, to Why this patient having the trouble with their swallowing so we can determine is it a delay?
[00:34:23] Nicole: Is there premature spillage? Is it because there's poor laryngeal vestibule closure or some kind of anatomical reason and knowing, you know why the patient's having trouble swallowing from there, then we can develop an individualized treatment program. So, that would be obviously another reason why you would refer us to kind of get a really.
[00:34:46] Nicole: Individualized treatment program. Yeah, and compensatory strategies that we can do because you can't trial, you know, a chin tuck unless you are using an instrumental study because sometimes a chin tuck can actually increase the patient's risk of aspiration.
[00:35:05] Renee: Yeah. And depending on, like you said, the diagnosis I've had you know, even though it was modified barium, but even with FEES, I've had some interesting patients who were like, their diagnosis wasn't a stroke or TBI or ALS or Parkinson's or anything like that.
[00:35:21] Renee: I had a couple of people that had intellectual disabilities who also had seizure disorders who were on medications for seizures and were eating had been placed on at their like group home or their facility that they lived at pureed within. And I had actually three different people within like a six month period who all aspirated only the pureed.
[00:35:46] Renee: And it was like the weirdest thing because they just, I think the text increased texture was better for them. And the physician that I was working with at the time kind of related it or connected it back to some of the anti seizure medications and that the sensation changes that kind of co occurred from the medication and in the presence of them having had seizures for a good long spell of their life had made the sensation changes in that musculature so that they thought Pureed was the safest.
[00:36:20] Renee: And then in all actuality, it wasn't, they could eat a regular diet, just fine. And the pureed was the trigger. And it was like a copious amount of like, you know, you're talking someone who doesn't necessarily have the best impulse control. And sometimes with instrumentals, we want to see that because we want to see what happens when we're not there.
[00:36:37] Renee: And so they would take these giant scoops of pudding and the giant scoop of pudding is now aspirated. And I'm like, whoa, That's not what I thought was going to happen. So, again, I think just familiarizing yourself cause the, the diagnosis can really vary in the medications that people take can really interact too.
[00:36:58] Renee: And so having the knowledge of what was happening prior to this new diagnosis is really important. Cause it's always like a little puzzle. Right. Like putting together. Oh, wow. They did this. And I wasn't expecting that based on the where the stroke occurred. I wasn't expecting that. But then you come to find out they have something else going on.
[00:37:18] Renee: That was pre morbid to the stroke, which makes total sense.
[00:37:22] Nicole: Yeah, thicker viscosity is definitely not always better. And we find that a lot with the liquids where patients are put on honey thick or nectar thick and actually due to the residue, they might be. Aspirating that, and then the thin liquids.
[00:37:40] Nicole: Maybe the patient's coughing here and there occasionally, but they're actually swallowing that safer and clearing the material from the airway. So that the thinner liquids might be better.
[00:37:53] Renee: Yeah. So what are some recommendations for ways that you can gain more competency? Because I think, and I, you know, I just think back to like my FEES training when I was, I was a CF and I went to, And I had a wonderful experience.
[00:38:11] Renee: So I had Beth Cormell out in Raleigh. I did my FEES training with her, but you know, we did the standard 25 observations, which were normals and abnormals, and then went to the course. And, you know, even after I went to the course and I had done several passes, I still had a lot of work to do to get to where I felt like I was, I won't even say competent, maybe not even the best word, competent enough.
[00:38:41] Renee: But it certainly gets better. Like the more I learned and the more I did it and the more that I sought out education. So what, what are some suggestions or recommendation for areas of competency that you would, you would recommend?
[00:38:56] Nicole: It's a good question. Cause we as speech pathologists really need to be competent in every aspect of care that we provide to our patients.
[00:39:03] Nicole: I mean, that's also, if you're, As C's, you know, have your C's, then ethically, we're obligated to kind of make sure that we're trained and competent in providing these services to the patient. So that includes FEES, and FEES is a competency, it's not a certification, so there's no special certification from ASHA or any other body.
[00:39:26] Nicole: There's no oversight from ASHA. We just need to get our training and competence. And we can perform this procedure independently. So some of the ways that we can do that attend, you know, first step, I guess, would be to attend an ASHA approved CE course. Traditionally, this is, So Susan Langmore wrote a very, like, great article on ASHA competency, so I'm kind of pulling a lot of this information from that.
[00:39:57] Nicole: She indicates that traditionally it's 12 full hours, completed in two full days, and includes at least four hours of hands on practice. And then take and complete an exam based on those components of the course, would be step two. Step three would be. Handling the scope on healthy volunteers. So this is where the numbers kind of gets into it.
[00:40:22] Nicole: But there are some states that have certain numbers that it's necessary to obtain, but not all states. So I know New Jersey, for example, it's 25. New York does not have any number. So that could mean you're competent after 10. That can mean you're competent after 50, but. Usually the more scopes or passes that you're getting, the more competent you'll be.
[00:40:45] Nicole: You do want to though check your state requirement.
[00:40:48] Nicole: You should get at least 10, I would say, before you're competent. And that's the number that Suzanne Langmore listed. But again, the number can vary from person to person. You want to document how many procedures you've performed on both normals or patients without dysphagia.
[00:41:07] Nicole: And then sometimes you'll use like simulation training devices. So some of these courses will have like a head model or mannequin as the first step before going into your normal passes. I keep putting that in air quotes because sometimes even when we do. the passes on volunteers, you might get some reflux or anatomy changes as well.
[00:41:33] Nicole: So this kind of helps a clinician to get a sense of what is normal because you need to know, you know, what's normal to know what's disordered. So get at least 10 passes on healthy volunteers with no dysphagia. Then after that, and usually again, your ASHA course should have those passes with it. But you can get them in other ways.
[00:41:55] Nicole: Like maybe someone at your facility will just kind of volunteer to be scoped, so a nurse or, you know, a CNA or something like that After that, step four would be to pass the scope and perform FEES on patients. So again, there's certain states that have a certain number for that. And you know, different people can be competent after a different number of procedures.
[00:42:23] Nicole: Susan Langmore uses 15 as the minimum should be performed under the direct supervision of a competent speech pathologist or physician. So for your first passes on patients. And then after that, step five would be a mentoring. So having someone kind of to be able to, you know, ask questions to to kind of maybe review your, your FEES, exams, and make sure that you're writing them accurately.
[00:42:53] Nicole: They might sign off on a competency assessment. So ASHA actually has a dysphagia competency forum on their website. That kind of goes through the different, you know, areas of competency. So I can kind of talk about that a little bit. It would be knowledge of like normal and normal and disordered swallowing.
[00:43:15] Nicole: So in terms of like the anatomy and physiology throughout the lifespan indications and contraindications of the FEES procedure, patient assessment elements of a comprehensive FEES. So maybe like your protocol and how to go about, you know, your exam in terms of looking at your, your laryngeal findings, looking at pre swallow tasks.
[00:43:43] Nicole: So vocal fold closure and posterior pharyngeal wall motion. So those kinds of things. Are involved in a comprehensive exam secretion management ability to managed their secretions and then the bullish trials how you're able to manage the actual equipment. Are you able to pass the scope adequately?
[00:44:05] Nicole: Are you able to manipulate the scope the right way? Maintain it, disinfect the equipment. So that's really important for infection control. Sometimes using topical anesthetic when appropriate in certain conditions manipulating the endoscope for the best position. So making sure you're getting a good view of the patient's whole anatomy and maybe even so there's two different views of the top of the airway and also going a little bit closer to make sure that nothing passes into the vocal cords and into the airway.
[00:44:40] Nicole: And a good view so that you're minimizing discomfort as well, and being able to direct the patient with a pro, you know, like, what should we do next now that the patient maybe did aspirate the thin liquids, what can we try to prevent that from happening, so what kind of maneuvers can we can we try with this patient.
[00:45:01] Nicole: And then after your, you have your mentoring, so that's step five. Then you might have like indirect supervision after that. So that's where you might ask your mentor, just like, you know, questions that come up periodically about specific patients that you might have difficult. And maybe it's remote where I always comply with like HIPAA regulations, but maybe that's done remotely where you send videos and they can kind of review those.
[00:45:30] Nicole: So those are the six I'd say steps for, for mentoring and for competency.
[00:45:38] Renee: Yeah. And I think it's important to note now too, there's there was also advanced FEES courses that I think when I first started, I don't remember there necessarily, there might've been one now there's a lot, or there are like refresher courses for people who may be.
[00:45:52] Renee: Not, not necessarily change practice settings, but maybe you went to a job where they didn't have a FEES program and you helped start it and now you haven't done it for a little bit of time and you want to make sure that you're competent and that your, your skill set is still up to speed because the passing of the scope is a skill that's separate from practice.
[00:46:11] Renee: The the other pieces of what we're looking at. And I think that was one of the harder things for me to describe to people that came into the health system who were not FEES competent prior to and they're not done any training because they're like, Oh, how hard can it be? And I'm like, okay, depends on the person you're scoping.
[00:46:29] Renee: Sometimes it's a little bit can be a real big challenge. So you have to be mindful of that. I know in Virginia where I'm at, we're not allowed to do any kind of topical anesthetics because that's considered medication. So that's one of those things too. You want to make sure that you're aware of what your state or locale requires or denies you being able to do.
[00:46:52] Renee: But one of the really cool things about being at the FEES course that I was at 400 years ago, we had a, an opera singer as one of our SLPs in the course. And so when we scoped her, she had a vocal fold hemorrhage. So again, we weren't able to say it like that, but our instructors were like, Oh, wow.
[00:47:14] Renee: And described it and, you know, sort of talked us through, this is what it is, but don't call it that. And then when I went back to the inpatient rehab we had a dietitian who, she described it as a Minnie Mouse voice. She always said she had a Minnie Mouse voice. That was how she described it, not how we described it.
[00:47:33] Renee: So she volunteered for scoping when I was going through my competency training. And she had had, A virus that caused her to have true vocal fold paralysis. And so she actually had a prosthetic on her vocal cord that kept her closer to midline on the one side. And so that was really cool because she didn't have dysphagia, but like if I had, if she hadn't volunteered, cause she thought it would be cool to see what it looked like herself.
[00:48:02] Renee: We wouldn't have had that experience. So you do get some kind of like really interesting. Volunteers, he'll just be like, yeah, this weird thing. Well, want to take a look at it? And I'm like, yeah, sure. And you look and you're like, what, you know, the competency can, it sounds daunting, but a lot of it can be such a great learning experience too.
[00:48:23] Renee: And I think, you know, being a CF when I did it, I was already so like nervous about literally everything I did, breathing, waking up in the morning. It was a lot of pressure and a lot of a challenge. But it was so cool to be able to have that experience that early on and see all those things. So yeah, I think it's the competency part can be really interesting and really fun.
[00:48:48] Renee: I think looking back at it is probably a lot more fun in my own mind now than there probably was at the time because there was a, yeah, now there's like, okay, no big deal. But I think the same speaks to tracheostomies because again, I was with someone as my clinical instructor as a student who had tracheostomy patients.
[00:49:11] Renee: And so I started out as a student. learning about trachs and just starting in the very basics of learning the parts. And this, it's a little bit different now because there's so many more manufacturers, they've changed a lot of the mechanics of the trach as far as the pieces and the parts now.
[00:49:30] Renee: Some of the things that make it extended or some of the things that maybe have been a little less commonly used depending on where you're at. Like the the permanent, more permanent cannulas, you see a lot more of the disposable or the removable ones. But, you know, that's another area that I think kind of ties in a little bit with our our competencies and talking about like just recommendations for how do you even see.
[00:49:55] Renee: start with tracheostomy because a lot of times what I've seen in the, especially in the acute care world is managers get really desperate for help, especially weekend coverage and stuff like that. And so they're like, Oh yeah, Sally Sue came from 25 years in the school system and not that there's anything wrong with that, but it's a big change.
[00:50:13] Renee: Just like, I don't feel like I would be good at. Going into a classroom that was maybe a a self contained classroom and, and working with kids with autism. That's just not, I'm not, I don't feel like I would be effective or competent in doing that. So I think the flip side is there. How would we start with competencies for looking at trachs and getting that education and that competency that we need.
[00:50:40] Nicole: Right. Cause that population patients with tracheostomy are at such high risk of preventable adverse events. So, and yeah, safety is a big issue with patients with tracheostomy and speech pathologists are having a more and more important role with this patient population. And we can do so much in terms of improving their quality of life and even improving patient safety as well.
[00:51:11] Nicole: Cause Our role can include, you know, communication management, so getting them assistive devices or AAC getting them speaking valves or talking trach tubes, so all those things we need to also be confident in. We can't just say, I've never seen this speaking valve before, let's see kind of what happens and put that on a patient because if you don't deflate the cuff, Yes, to me, then the patient can actually not be able to breathe and could die.
[00:51:46] Nicole: So we really need to be competent in this area. So communication, swallowing management, patients are at such high risk of aspiration. There's crazy statistics, like up to 80. 6 percent aspirate and of those, it's over 50 percent or silent aspiration. So you're not coughing or choking at bedside and these food coloring modified Evans blue dye tests that some clinicians provide food and liquid dyed blue or green.
[00:52:17] Nicole: Those tests are not sensitive. So, you know, You give them food with blue food coloring, you suction them, and you get blue, that means they aspirate it, but if you don't get blue, that could mean they're still aspirating, you just didn't suction the right spot to be able to remove that material. So we really need to be careful with this population.
[00:52:40] Nicole: Also, with decannulation, we're having more and more in a role with that as well. So, secretion management, cough strength, swallowing, and the use of FEES to determine if these patients are candidates for decannulation from our perspective. I mean, we're not the ones that are like, Yeah, now that I say that the patient, the trach removed, it's always the physician who at the end of the day has the you know, writes the order for removal of the trach, but we have such a big role.
[00:53:09] Nicole: So competencies in those types of things, the first step might be webinars online. So, tracheostomy education has a lot of webinars past the same year where you're viewing these webinars on so tracheo education has swallowing management verbal communication strategies where it goes through different types of speaking valves and talking trachs and how to You know, provide those to your patients safely trach care webinars and trach teams to get your facility kind of all on the same page.
[00:53:48] Nicole: Trach teams are kind of a really great multidisciplinary way to keep track of everyone and make sure everyone, I'm going off, but Off target. But anyway, so the first step would be webinars. Second step might be to get some hands on training, maybe use some simulation devices, so a mannequin that kind of appears like, a person you're, you're getting training in suctioning, you're getting training in deflating the cuff, placing a speaking valve.
[00:54:20] Nicole: You can also, yeah, those are the main things talking trach tubes. You can kind of do that on a, on a mannequin as well. Have a ventilator. We actually have an in person tracheostomy course coming up in June 22nd in New York. So those kinds of things are, are great to to go to some kind of hands on training.
[00:54:42] Nicole: And then the third step. Definitely like in your facility, having someone that already, you know, sees trach patients and they can kind of, or getting someone from the outside to come in, to train you on the patients and actually going and suctioning the patient and, you know, In each state has different laws about suctioning too for speech pathologist.
[00:55:05] Nicole: We are able to do it in New York. And then your facility also needs to say, yes, you can do it. So having like protocols for all of those things that we talked about, and then also having a competency where, you know, each step someone signs off, yes, they can deflate the cuff. Yes. They're able to suction.
[00:55:22] Nicole: Yes. They're able to place the speaking valve. So those would probably be, The, the steps to competency. And trach education does have some papers that kind of show what exactly kind of what I went through, but how to become competent in those areas.
[00:55:44] Renee: Yeah. Again, when I was in inpatient rehab, we had an LTAC floor.
[00:55:49] Renee: And so we got to do respiratory rounds with the respiratory therapist and the pulmonologist. So that was a great way to get hands on training so that you didn't necessarily have to be the person that was doing the things, but you could go in and observe the things and listen to the rounds of what this patient's case history looked like, what had been done respiratory wise learn about ventilator settings, learn about.
[00:56:15] Renee: The trach stuff and like how be, you know, downsizing and when that was done. And there was a lot, there's just a lot to learn. And I think even having that part, if you're not the one going in, like in Virginia, we can't suction, we can suction outside of the cannula, but we cannot go down inside. So we can't do that.
[00:56:35] Renee: That's a respiratory therapy thing. And so, but being in the room and seeing it done and being like more comfortable seeing it, cause some people it's just not their thing. And then other people, like, I don't, I don't want to see, sorry, this is going to be weird, but I don't want to see poop. But if you want to get.
[00:56:54] Renee: Or if they throw up and I got to like suction them when I'm, you know, in there, I don't care. That doesn't bother me. I guess I'm weird. Like, I think that that's that's another space where you just, you kind of get a little bit more comfortable with that. I'm seeing that we're getting a few questions here.
[00:57:14] Renee: So if you're okay with kind of moving into that realm, Nicole, does you want to add anything? Okay. So someone said, Alyssa said, do you feel that MBS IMP is adequate training? I think, I mean, I can answer, or we can both answer. So if you're talking about FEES, then no, cause that's modified barium swallow training.
[00:57:33] Renee: But when it comes to modified barium swallow training, I would say that that's I mean, I'm not going to endorse it as far as I don't get paid by them or anything like that, but I do think it's good. Training. I know a lot of the students in our dysphagia program at our university do the MBS IMP student training.
[00:57:52] Nicole: Yeah. I also think it's great just for norm knowing part of what you need to know for feeds is normal and I'm swallowing. So just, it does go through that pretty very well.
[00:58:04] Renee: Yeah. I think the anatomy, yep.
[00:58:06] Nicole: That underlying knowledge and then go to like a basic FEES course. So they have a lot of FEES courses throughout the country to, to help train yourself in FEES.
[00:58:19] Nicole: We have some on the site that are listed on endoscopy dysphagia specialists. If you wanted to look at that, like different places where you can get basic FEES trained and What's that?
[00:58:33] Renee: Oh, I was just going to say, I don't want to go out of order, but that this one's more related to what you just said.
[00:58:38] Renee: So someone said is the website for trach webinars, tracheeducation. com.
[00:58:43] Nicole: Oh, it's called tracheostomyeducation. com. T R A C H E O S T O M Y. education. com.
[00:58:51] Renee: I and then someone else said, hold on, I gotta go back here. What's the difference between nasoendoscopy and FEES?
[00:59:01] Nicole: So nasoendoscopy is when you, is the placement of the nasoendoscope into the nares.
[00:59:10] Nicole: It's, Like, we use a nasoendoscope for FEES. Nasoendoscopy would be more of a procedure that an ENT would perform to check the nasal passages for You know, I need anatomical deficits in the nose.
[00:59:30] Renee: And then the other question is, is FEES training just on adults or peds too?
[00:59:36] Nicole: You would have, most of the FEES courses that I know of are adults.
[00:59:41] Nicole: They do have some pediatric FEES training and it's usually all about pediatric FEES. So it's usually a separate training because for me as an adult FEES specialist, I would, I can't even touch a little peed. It's totally different anatomy, physiology. So yeah, you would need two separate courses to be competent in both areas if you wanted to do both adults and peeds.
[01:00:07] Renee: Yeah, I agree because that people are like, Oh, you could do Pete's feeding. And I'm like, it's, it's different than what I do adapt. I'm not scared of children. I have children. Like it would scare me to think I've got this little tiny person. And I think that, again, that's one of those things. That's definitely a personal preference.
[01:00:26] Renee: And I think if you felt like you wanted to get trained on both, it's certainly. Yeah, sure. You could, but I know my FEES training and the ones that we've sent our. staff to throughout the years have all been for adult medical based, but all excellent questions. Where can one train for peds?
[01:00:45] Renee: I personally have no idea. That would be a good question for like feeding matters may know the feeding matters. I think it's. org website. They have questions like question and the answers are people that you can email. In the pediatric feeding disorders world, I think that would be a great way to find out because I have never personally seen just a a one training for peds for FEES.
[01:01:14] Nicole: I see one in Texas. It's the facet. org. I don't know anything about it, though. I just.
[01:01:24] Renee: But Nicole, thank you so much for joining us. This was really helpful and I appreciate you being so proactive and, you know, answering the questions and having everything prepared. It's just, it's always good to speak to somebody who comes on and has such a good wealth of knowledge to share. Thanks again, Nicole. I look forward to seeing you again.
[01:01:46] Nicole: Thank you.
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