Introduction 1 2 2 3 4 Based on these considerations, we prospectively evaluated a diagnostic protocol using routine fiberoptic endoscopic evaluation of swallowing (FEES) in critically ill patients at risk to develop aspiration following temporary transnasal intubation or tracheotomy and tried to define the impact of post-extubation FEES on the initiation of aspiration-related treatment. Material and methods We conducted a prospective, interventional, clinical study at Klagenfurt General Hospital. The hospital is a 1,400-bed tertiary referral centre that serves a population of approximately 1,000,000 and runs seven ICUs (paediatrics and neonatology, 1; neurology, 1; neurosurgery, 1; cardiology, 1; general internal medicine, 1; and anaesthesiology, 2) with a total of 84 beds. Weight loss, unexplained fever >38.0° centigrade, coughing, bronchitis/pneumonitis, impaired voice, witnessed regurgitation/aspiration event at the bedside accompanied by coughing, choking, and/or expectoration of material, prolonged oral feeding, aversion for oral intake of liquids and solids, disturbance of bolus transport, frequent postural changes during oral intake, and regurgitation. The FEES procedure was consequently provided by staff members of the department of Oto-Rhino-Laryngology, Head and Neck Surgery. The team consisted of a laryngologist and a nurse who had both previously gone through a specialized training in performing FEES procedures in patients with deglutition disorders. Over the 45-month period from 1 January 2002 to 30 September 2005, we were called to perform 913 endoscopic examinations in 553 patients treated in one of the ICUs. Four hundred and 46 patients underwent one single endoscopy, and 107 had repeated examinations. Two hundred and 95 patients had shortly before been extubated after transnasal tracheal intubation, and 258 patients had indwelling tracheotomies. For further data interpretation, patients were sub-grouped according to their route of ventilation (transoral/transnasal intubation vs. tracheotomy). Findings and recommendations from the initial FEES procedure in all 553 patients were accumulated for this study. The results of 360 control procedures were not further analyzed. Details of the FEES procedure have previously been described in detail. Therefore, only a short summary of the procedure shall be given here: The FEES procedure is a portable examination, easily taken to bedside in ICUs. Since our patients were usually bedridden, we performed the examination in a in bed with the head of bed elevated to approximately 70° with the bend of the bed is at the patient’s lower back (904/913 patients, i.e., 99%). In four patients (0.4%), the examination was carried out with the patient in reverse Trendelenberg at 30°–45°, and five patients (0.6%) were able to sit on a chair during the procedure. A fiberoptic laryngoscope was passed transnasally to the oropharynx, where the larynx and surrounding structures could then be visualized. Patients were led through various tasks to evaluate the sensory and motor status of the pharyngeal and laryngeal mechanism. Stained liquid and semi-liquid boluses were then given to determine the integrity of pharyngeal deglutition. The interior larynx and airway were examined for evidence of food penetration within the laryngeal vestibule and aspiration of food below the true vocal folds before and after each swallow. In each case, the nasogastric tube was removed prior to the procedure. We assessed structural changes of the larynx and pharynx, timing and direction of movement of the bolus through the pharynx, the ability to protect the airway and to uphold airway protection for a some seconds, the capability to clear the bolus during deglutition, presence of pooling and residue of material in the hypopharynx, and timing of bolus flow and laryngeal closure. Aspiration was defined as the entry of material into the airway below the levels of the true vocal cords. Silent aspiration was defined as aspiration occurring in the absence of acute symptoms (i.e., lack of cough or gag reflex as the food or liquid bolus passed into the trachea). Findings were documented in a standardized form to allow for monitoring therapeutic interventions over time, and for later data analysis and evaluation. Results Modifications in volume and tempo of food presentation oral feeding with consistency modifications head rotation holding the chin down during deglutition to narrow the airway entrance supraglottic swallow: This technique uses simultaneous swallowing and breath-holding, closing the vocal cords and protecting the airway. 1 2 3 4 Table 1 Symptoms of aspiration in 553 patients  n n Unexplained fever 17 (5.8%) 39 (15.1%) Coughing 68 (23.1%) 31 (12.0%) Bronchitis/pneumonitis 57 (19.32%) 39 (15.1%) Impaired voice 57 (19.32%) 0 (0%) Witnessed regurgitation/aspiration event  74 (25.1%) 149 (57.8%) Others 16 (5.4%) 23 (8.9%) No data 69 (23.3%) 19 (7.4%) Since more than one symptom or sign could apply per patient, results sum up to more than 100% Table 2 Route of feeding for 553 patients on initial FEES  n n Nasogastric tube 224 (75.9%) 186 (72.1%) PEG 15 (5.1%) 59 (22.9%) Parenteral 12 (4.1%) 5 (1.9%) Oral diet 44 (14.9%) 8 (3.1%) PEG Table 3 Classification of aspiration for 553 patients on initial FEES  n n Silent aspiration 51 (17.3%) 95 (36.8%) Aspiration 115 (39.0%) 126 (48.8%) No aspiration 129 (43.7%) 37 (14.4%) Aspiration = inhalation of material into the airway below the level of the true vocal cords, with acute symptoms (cough or gag reflex as the bolus passed into the trachea), silent aspiration = aspiration occurring in the absence of acute symptoms Table 4 Recommendation for further treatment in 553 patients after initial FEES  n n Non-oral feeding (naso-gastric tube) ± logopedic (functional) therapy 144 (48.8%) 131 (50.8%) Indication for PEG 27 (9.1%) 46 (17.8%) Indication for non-oral feeding plus tracheotomy 35 (11.9%) NA Oral feeding ± logopedic (functional) therapy 89 (30.2) 22 (8.5%) Decannulation and oral feeding ± logopedic (functional) therapy NA 59 (22.9%) PEG NA Discussion 5 45% in normal individuals during sleep 70% in patients with impaired consciousness 0–40% in patients on ETF 50–75% in patients with endotracheal tubes 5 6 7 8 4 9 Video-fluoroscopy has traditionally been accepted as the “gold standard” for evaluation of a swallowing disorder for the comprehensive information it provides. However, it is not very efficient and accessible in certain clinical and practical situations. This is particularly true for critically ill patients treated at ICUs, who are almost invariably bedridden. 4 10 13 14 20 12 15 17 19 21 22 23 24 4 25 26 Our results allow no conclusion regarding the impact of tracheotomies on deglutition, since the initial decision to perform a tracheotomy had not been randomly assigned to patients in our two subgroups. The decision to perform tracheotomies was not consistent over different ICUs and largely depended on the anticipated length of assisted ventilation. In our study, FEES was used to determine the need for maintaining tracheotomy, and was accepted by ICU physicians as an important criterion in deciding to close tracheotomies following assisted ventilation. Conclusion After the introduction of a standardized endoscopy protocol for critically ill patients considered being at risk for silent aspiration, ICU physicians soon requested FEES routinely for their patients. FEES in critically ill patients allows for a rapid evaluation of deglutition, for targeted further diagnostic procedures if needed, and for the immediate initiation of symptom-related rehabilitation or for an early resumption of oral feeding. FEES is now accepted at our institution as an important tool in achieving timely and appropriate clinical decisions for ICU-patients at risk for aspiration-related morbidity. Laryngologists should be encouraged to offer FEES procedures to responsible coordinators of ICUs.