The Safety and Utility of Early Swallow Assessment Using Flexible Endoscopic Evaluation of Swallowing (FEES) in Patients Requiring Extra Corporeal Membrane Oxygenation (ECMO): A Case Series (Four Reports)

Case 1

A thirty-three-year-old female with pleuro-parenchymal fibroelastosis was admitted for single lung transplant. ECMO was required for sixteen days post-surgery, following challenges with CO² retention. Tracheostomy was inserted three days post-surgery. Nine days post-surgery, sedation was weaned and SLT assessment requested. Initial clinical swallow assessment identified indications for an early FEES; whilst laryngeal function appeared reasonable, visualisation would rule out silent aspiration given ongoing cuff inflation. Risks related to nasendoscopy, epistaxis and anticoagulation therapies were mitigated by discussion with the medical team; deeming her safe to remain on heparin for the procedure. FEES was performed two days after initial SLT assessment, at which point cuff deflation and passy muir valve (PMV) intervals were undertaken during waking hours. FEES identified intubation-related laryngeal injury involving both vocal folds and unilateral vocal fold immobility reducing glottic closure, airway protection and voice. Dysphagia symptoms also included reduced pharyngeal strength, breath-swallow incoordination and laryngeal penetration. As detailed in Table 1, FEES enabled safe and immediate commencement of IDDSI Level 0 thin fluids and IDDSI Level 4 thick puree, with progression to IDDSI Level 7 regular diet under SLT guidance within eleven days. In this case, FEES accurately detected intubation trauma and dysphagia, facilitating a less cautious approach, earlier safe oral intake (see Table 2) and reduced dependence on tube feeding. No adverse scoping or aspiration pneumonia events were reported.

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Table 1.

FEES Outcomes

	Case 1	Case 2	Case 3	Case 4
Yale Residue Severity Scale (Neubaher et al., 2015)	IDDSI Level 0–B	IDDSI Level 0–B	First FEES	First FEES
	IDDSI Level 4–B	IDDSI Level 6–D	IDDSI Level 0–B	IDDSI Level 0–D
	IDDSI Level 6–D	IDDSI Level 7–D	IDDSI Level 4–D	Further trials not given due to lack of pharyngeal space, strength and residue observed on thin fluids
			Second FEES	Second FEES
			IDDSI Level 0–B	IDDSI Level 0–B
			IDDSI Level 2–B	IDDSI Level 4–C
			IDDSI Level 4–D	IDDSI Level 5–C
			Third FEES	IDDSI Level 6–C
			IDDSI Level 0–B
			IDDSI Level 4–B
			IDDSI level 6–B
			IDDSI Level 7–D
Penetration Aspiration Scale (Rosenbek et al., 1996)	IDDSI Level 0 small sip–1	IDDSI Level 0 small sip–1	First FEES	First FEES
	IDDSI Level 0 large sip–3	IDDSI Level 0 large sip–3	IDDSI Level 0–one occasion of PAS 8, all other trials PAS 1	IDDSI Level 0–3 (initially very trace, built up with more trials)
	IDDSI Level 4–1	IDDSI Level 6–1	IDDSI Level 4–1	IDDSI Level
	IDDSI Level 6–6	IDDSI Level 7–1	Second FEES	Second FEES
			IDDSI Level 0–8	IDDSI Level 0–B
			IDDSI Level 2–5	IDDSI Level 4–C
			IDDSI Level 4–1	IDDSI Level 5–C
			Third FEES	IDDSI Level 6–C
			IDDSI Level 0–1
			IDDSI Level 4–1
			IDDSI Level 6–1
			IDDSI Level 7–1
Strategies	Clearing swallows and fluid washes cleared residue effectively. Penetration cleared with prompted throat clearing and swallows	Fluid wash effectively cleared residue	Prompted cough ineffective at reversing aspirated or penetrated bolus	Effortful swallow on first FEES – ineffective

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Table 2.

Timeline of Patients Progress to Oral Intake

	Case 1	Case 2	Case 3	Case 4
ECMO commencing to tracheostomy placement	3 days	26 days	4 days	51 days
ECMO commencing to initial FEES	12 days	81 days	44 days	56 days
Reason for delays in FEES post-ECMO commencing	High levels of sedation due to agitation	Inconsistent levels of alertness and absent swallow trigger	Heavy sedation due to multiple bronchoscopies and theatre trips for wound management	Intubation and heavy sedation
Initial FEES to commencing oral intake	0 days	0 days	0 days	0 days
Commencing oral intake to ECMO decannulation	7 days	1 day	40 days	15 days
Commencing oral intake to tracheostomy decannulation	49 days	13 days	50 days	58 days
Commencing oral intake to step down from Critical Care	56 days	20 days	71 days	61 days

Case 2

A forty-four-year-old gentleman was escalated to critical care on day four of hospital admission for severe pneumonitis. Previous medical history included HIV, asthma and hypertension. He required intubation, sedation, mechanical ventilation and ECMO due to severe respiratory acidosis and raised PCO². An adjustable flange size 9 tracheostomy was inserted on day twenty-six and SLT requested. Conscious level was variable, delaying SLT intervention, however once awake, assessment identified absent swallow function. High ventilatory requirements and instability deemed cuff deflation unsafe. SLT intervention supported communication and the cautious introduction of oral trials, sixty-seven days after commencing ECMO. FEES was indicated due to clinical vulnerability, concerns that prolonged intubation impacted laryngeal sensation and the degree of dysphagia severity on assessment. FEES identified weak base of tongue movement, laryngopharyngeal oedema and a resolving posterior glottic intubation granuloma but silent aspiration was ruled out (see Table 1). In this case, FEES enabled rapid progression of oral intake to IDDSI Level 0 thin fluids and IDDSI Level 7 regular diet, despite ongoing severe respiratory compromise, improving both patient mood and nutritional status (see Table 2).

Case 3

A thirty-five-year-old gentleman with Langerhans histiocytosis underwent a double lung transplant with ECMO. A rise in CO² and ventilatory pressure support prevented ECMO weaning and a decision was made for tracheostomy insertion on day four. Frequent theatre interventions for anastomotic dehiscence, right bronchopleural fistula, and bronchoscopies necessitated prolonged sedation. Forty-two days post transplantation and commencement of ECMO, sedation wean enabled SLT clinical swallow assessment. A breathy dysphonic voice quality indicated potential intubation injury to the larynx and subtle signs of laryngeal penetration on oral trials were suspected; therefore, FEES was recommended. Discussion with the ECMO consultant regarding bleeding risks enabled FEES to continue with heparin and cuff deflation with PMV, following a protracted period of cuff inflation. FEES identified bilateral vocal fold immobility with incomplete glottic closure, sensory-motor dysphagia, with a delayed swallow, reduced pharyngeal constriction and airway penetration of residue on harder textures (see Table 1), a. Sips of IDDSI Level 0 thin fluids and IDDSI Level 4 thick puree were commenced (see Table 2) alongside exercises targeting laryngopharyngeal weakness (effortful swallow and chin tuck against resistance).

Respiratory acidosis, bibasal lung collapse and further anastomotic dehiscence led to a medical decision to change the single lumen tracheostomy to a Rusch double lumen tube; allowing BiPAP ventilation to the left lung, and CPAP valve circuit to the right lung for anastomotic healing. PMV use was paused whilst ventilation was optimised. SLT performed a further FEES to ensure no detriment to swallow function from altered ventilation and tube change. Whilst FEES showed improvement in pharyngeal and swallow strength, laryngopharyngeal sensation and silent aspiration had worsened, likely due to the larger tube size restricting upper airway airflow, and lack of PMV diminishing sensation and subglottic pressure. Oral fluids were no longer safe, but IDDSI Level 4 thick puree continued safely.

PMV use re-commenced and a further FEES identified improved laryngopharyngeal sensation, enabling commencement of IDDSI Level 0 thin fluids and IDDSI Level 6 soft/bite-sized diet, returning to IDDSI Level 7 regular diet one week later.

In this case FEES facilitated accurate monitoring of swallow function during tube changes and turbulent recovery. Safe oral feeding continued despite medical deterioration. Serial FEES was invaluable in preventing aspiration complications and facilitated flexible dysphagia management during critical illness. The huge psychological benefits of early FEES were highlighted by the patient who reported feeling ‘close to depression’ whilst nil-by-mouth and ‘being able to eat and drink was a big step, improvements I could see’.

Case 4

A twenty-nine-year-old female with a new diagnosis of HIV, but no previous medical history, was admitted with pneumocystis pneumonia and cytomegalovirus pneumonia. She required intubation due to failure to thrive on non-invasive ventilation. ECMO was commenced nine days later due to acidosis and hypercapnia. An adjustable flange tracheostomy was inserted fifty-nine days later. Improved alertness facilitated SLT clinical swallow assessment. Lung fibrosis and high ventilation requirements prevented cuff deflation and absence of a subglottic port precluded ACV. Swallow weakness was evident on assessment and, due to SLT workforce availability, FEES was performed five days post tracheostomy during ongoing cuff inflation and heparin. FEES was indicated as the patient was alert and tracheostomy cuff inflation was essential to optimise ventilation.

FEES identified laryngeal erythema and oedema, bilateral vocal cord paresis, severe sensorimotor dysphagia with delayed swallow and pharyngeal residue symptoms. Oedema obliterated the pyriform sinuses, causing silent aspiration of residue overspilling into the airway. As detailed in Table 1, small quantities of IDDSI Level 0 thin fluids were visualised as safe despite cuff inflation, alongside swallow exercises targeting physiological weakness. Discussion with the medical team agreed on deferring the use of steroids for oedema, opting to monitoring whether increased swallow activity from introducing oral intake was effective.

Fourteen days later during a tracheostomy tube change, respiratory function deteriorated requiring re-sedation. Two days later sedation was weaned, ECMO was decannulated, and SLT supported re-commencement of dysphagia exercises, observing increased hyolaryngeal excursion and swallow strength. Repeat FEES was indicated and twenty-eight days after initial FEES found no change in laryngeal oedema but improvement in swallow strength. IDDSI Level 0 thin fluids and IDDSI Level 5 minced/moist diet were safe with cuff inflation. Fourteen days later, clinical swallow assessment during short periods of cuff deflation and PMV confirmed safety of continuing oral intake. Jaw and tongue strengthening exercises supported chewing ultimately enabling return to IDDSI Level 7 regular diet nineteen days later.

In this case FEES supported safe oral feeding with the cuff inflated on ventilation two weeks prior to cuff deflation, with no adverse effects (see Table 2).