Mobile Flexible Endoscopic Evaluation of Swallowing (mFEES) in Adults in Residential Aged Care Homes (RACHs): a feasibility study

Intervention: A single session of flexible endoscopic evaluation of swallowing (FEES) was provided to residents who were referred by their treating speech pathologists for assessment if (i) they consent to the procedure, (ii) met safety criteria, and (iii) a treating medical practitioner (e.g., GP, geriatrician) supported the assessment. The duration of assessment (between 15m-35m), the textures of food and fluids presented, the number of oral trials and strategies to optimise swallowing safety, efficiency and comfort were tailored to the individual needs of each resident based on the speech pathologist's clinical findings and the resident's choices. The FEES involved passing a thin flexible endoscope connected to a light source, camera, and video-recording equipment transnasally to the level of the nasopharynx, oropharynx, and hypopharynx. During the FEES the resident was required to: (i) perform a series of behavioural tasks (e.g., puffing out of cheeks, poking out the toungue, phonation tasks, coughing, swallowing saliva, and breath holding); (ii) swallow oral intake; and (iii) watch the video screen for biofeedback (if appropriate). This enabled the endoscopist to assess the resident's pharyngeal and laryngeal structures and function related to swallowing. When clinically indicated, the endoscopist directed the resident to implement specific behavioural strategies to assess their impact on swallowing safety, efficiency, and comfort (e.g., taking small mouthfuls, flexing the neck during the swallow, concentrating before swallowing, breath holding during the swallow) The minimum number of oral trials that participants were instructed to complete were 3 x trials of fluids and 3 x trials of food. Fluid consistencies ranged from thin (IDDSI L0) to mildly thick (IIDSI L2) to moderately thick (IDDSI L3). Food consistencies ranged from pureed (IDDSI L4), to minced and moist (IDDSI L5), to soft (IDDSI L6), to regular food (IDDSI L7). Within 7 days from the FEES procedure, the endoscopist (research speech pathologist) and a consulting otolaryngologist/ speech pathologist analysed the FEES recording to produce a report describing: (i) airway protection mechanisms; (ii) pharyngeal/ laryngeal sensation; (iii) pharyngeal swallow function; (iv) morphological observations; and (v) secretion management. This report contained written information and photo images that could be used by the facility (treating speech pathologist) to: (i) formulate a tailored swallowing management plan (e.g., prescribe specific food/ fluid consistencies, prescribe exercises to strengthen muscles for swallowing, prescribe the manner of oral intake such as small mouthfuls and rest between swallows) ; (ii) educate the resident and their healthcare team about the resident's swallowing function; (iii) formulate a more specific dysphagia prognosis. It was not the role of the endoscopist to provide swallowing management recommendations because the treating speech pathologist was in a better position to facilitate a multidisciplinary management plan due to their ongoing, wholistic knowledge of the resident and the ability to incorporate resident choice into care options. Where: FEES was provided onsite in the resident's bedroom in the residential aged care home Who: A speech pathologist conducted the endoscopy and guided oral feeding during the FEES. The RACH division one nursing staff member, who was familiar with the resident, administered the food/ fluids during the assessment as per the speech pathologist's directions. An on-call otolaryngologist was available via telephone and online media, if assistance was sought by the speech pathologist, to offer advice about anatomical concerns. Recordings of the FEES were analysed by two experienced speech pathologists, with optional input from the otolaryngologist on a needs basis. The report was prepared within one week of assessment by the speech pathologist who conducted the FEES. This report was provided to the referring speech pathologist and the RACH where the resident lived. Fidelity: Data were collected on the number and nature of adverse events occurring during the FEES and the number of adults who tolerated the procedure.