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Fiberoptic endoscopic evaluation of swallowing andvideofluoroscopy swallowing assessment of adults inresidential care facilities: a scoping review protocol

Olga Birchall1,2 � Michelle Bennett3 � Nadine Lawson4 � Susan Cotton5,6 � Adam P. Vogel1,7,8

1Centre for Neurosciences of Speech, The University of Melbourne, Melbourne, Australia, 2Department of Audiology and Speech Pathology, The

University of Melbourne, Melbourne, Australia, 3School of Allied Health, Australian Catholic University, North Sydney, Australia, 4Speech Pathology

Department, Cabrini Hospital, Malvern, Australia, 5Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Australia,6Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia, 7Department of Neurodegeneration, Hertie Institute for Clinical

Brain Research, University of Tubingen, Tubingen, Germany, and 8Redenlab, Melbourne, Australia

A B S T R AC T

Objective: This scoping review will identify and explore existing evidence on the use of instrumental swallowingassessment in the diagnosis and management of dysphagia in adults living in residential care facilities.

Introduction: Oropharyngeal dysphagia is prevalent among adults living in residential care facilities. Video-fluoroscopy and fiberoptic endoscopic evaluation of swallowing are instrumental assessment procedures commonlyutilized in the evaluation of oropharyngeal dysphagia in hospital and community settings. However, little is knownabout the use of these procedures in residential care facilities. To ensure evidence-based assessment of oropharyn-geal dysphagia and to guide future research, exploration of the current use and clinical utility of videofluoroscopyand fiberoptic endoscopic evaluation of swallowing in residential care facilities is needed.

Inclusion criteria: Published and gray literature written in English between 2000 and 2019 that discussesinstrumental swallowing assessment of adults in residential care facilities will be included in the review.

Methods: A three-step search strategy will be used to explore relevant literature. All citations and articles retrievedduring the searches will be imported into a software application for systematic reviews. Once duplicates areremoved, two reviewers will screen the titles and abstracts against predefined inclusion criteria. Information will beextracted from literature that meets the selection criteria using a purposefully developed charting form. The searchstrategy and results will be illustrated through a Preferred Reporting Items for Systematic Reviews andMeta-Analysesdiagram. Key findings and their relationship to the research questions will be summarized in a chart and discussed ininterpretive narrative form.

Keywords Dysphagia; Fiberoptic Endoscopic Evaluation of Swallowing and Videofluoroscopy; geriatric; nursing;residential

JBI Database System Rev Implement Rep 2019; 17(0):1–12.

Introduction

A dults who are living in residential care facilities(RCFs) are likely to experience many health

problems that increase their risk of developing oro-pharyngeal dysphagia (OD). Prevalence of OD amongadults in RCFs has been reported to be between 40%and 68%.1-5 Prevalence rates vary depending on thetype of screening tool, care setting, medical diagnosis

and country of investigation.6-8 Furthermore, there isa lack of information on how OD is assessed in RCFcohorts, the frequency of instrumental swallowingassessment tool use, and barriers and facilitators asso-ciated with assessment procedures.

Oropharyngeal dysphagiaOropharyngeal dysphagia is a real or perceivedimpairment in the safety and efficiency of formationand movement of food or liquids from the oral cavityto the esophagus.9,10 Oropharyngeal dysphagia mayoccur due to one or a combination of differentetiologies, including: neurological conditions (e.g.

Correspondence: Olga Birchall, [email protected]

The authors declare no conflict of interest.

DOI: 10.11124/JBISRIR-D-19-00015

JBI Database of Systematic Reviews and Implementation Reports � 2019 THE JOANNA BRIGGS INSTITUTE 1

SYSTEMATIC REVIEW PROTOCOL

©2019 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

mailto:[email protected]

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stroke), structural anomalies (e.g. osteophytes),neurodegenerative diseases (e.g. dementia, Parkin-son’s disease, motor neuron disease), head and neckcancer, and respiratory compromise (e.g. chronicobstructive pulmonary disease).10 These etiologiesare become more prevalent with increasing age.Sarcopenia, described as age-related changes in headand neck anatomy, and neural and muscular physi-ology may also lead to reduced functional reserve inolder adults,8 increasing dysphagia susceptibility inolder age. One study found lifetime dysphagia prev-alence of 38% in adults aged 65-94 years.11

Potential sequelae of OD include malnutrition,dehydration, aspiration (potentially resulting in aspi-ration pneumonia), increased hospital readmissionswith pneumonia, institutionalization, choking anddeath.8,10 Mortality rates of up to 50% have beenreported in adults in RCFs with known aspiration.12

Psychosocial consequences of OD include feelings ofembarrassment,13 anxiety,14 fear of choking,13

reduced self-esteem,13 lowered mood or depression,14

reduced quality of life,14 social isolation13 and physi-cal burden on caregivers.6 Oropharyngeal dysphagiaalso poses economic implications likely to increasewith global aging. A US study identified that patientswith dysphagia had, on average, a 40% increase inlength of stay compared to patients without dyspha-gia, resulting in an additional USD $547 million perannum in associated healthcare costs.15,16

Assessment procedures for oropharyngealdysphagiaIt is generally accepted that accurate assessment isessential for appropriate dysphagia prognosticationand management.17 However, current dysphagiamanagement is heavily based on anecdotal evidenceand expert opinion, with limited robust researchevidence available that is applicable to the broadpopulation of older people living in RCFs.10,18 Todate, most studies of dysphagia screening, assess-ment and management have been focused on certainpopulations, such as people with neurogenic disor-ders19-22 (e.g. stroke) and head and neck cancer23,24

in acute, rehabilitation or outpatient settings.19-22

Little is known about the procedures in RCFs. Oneof the major ethical considerations for conducting aswallowing assessment is its potential to result inimproved care. To be considered beneficial, swal-lowing assessments should be supported by access toappropriate dysphagia management. Historically,

availability of dysphagia care in RCFs has beenlimited, in contrast to care in hospital settings.25

In some developed countries there is a trend towardsconsumer-directed dysphagia care25 and healthcarestandard regulation in RCFs.26

Clinical swallowing examinations (CSEs) may beused to confirm suspected OD, provide data about thenature and severity of dysphagia,27 and determinewhen additional diagnostic information is required.Clinical swallowing examinations are utilized as theinitial step in evaluation. The components of a CSEmay include: i) medical and swallowing history, ii)oral hygiene evaluation, iii) structural oromotor andneurological assessment of cranial nerves (specificallyfive, seven, nine, 10 and 12), iv) cognitive-communi-cation observations, and v) swallowing trials withselected food and fluid consistencies.10,27 Oral andpharyngeal stages of swallowing are observed, withspecial attention to behavioral signs and reportedsymptoms that suggest physiological impairments(e.g. multiple swallows per mouthful, reflexive cough,wet vocal quality, dyspnea or increased respiratoryrate post-swallowing). Using clinical reasoning, theexaminer evaluates and synthesizes relevant informa-tion from the CSE.28 In some cases, CSEs may providea clear diagnostic picture. In other cases, CSEs revealareas where further diagnostic information is requiredto guide dysphagia management.

Clinical swallowing examinations do not requirespecialized instrumentation and can be rapidlyadministered in a variety of settings. Problems asso-ciated with CSEs include limited specificity in deter-mining swallowing physiology,29 variability incomponents evaluated by each examiner30-32 andexpertise of individual examiners influencing theinterpretation of the CSE.33

Given these issues, there has been increasing sup-port and evidence for instrumental swallowing assess-ments to be utilized after CSEs, as a key feature ofdysphagia management, especially when additionalinformation is required about aspects of swallowingphysiology.10 Instrumental assessment of swallowinghas many benefits over CSE alone. It provides a meansto identify the presence and degree of aspiration, thesite and volume of pharyngeal residue, pharyngeal/laryngeal sensation, and the effectiveness of compen-satory and rehabilitative strategies.10 These findingscan be used to reduce aspiration risk and aspiration-related morbimortality.34 Instrumental assessmentmay also help to define the risks and advantages of

SYSTEMATIC REVIEW PROTOCOL O. Birchall et al.



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oral intake,35 leading to more informed and patient-centered choices.

Videofluoroscopy swallowing study (VFSS) andfiberoptic endoscopic evaluation of swallowing(FEES) are the two most commonly used instrumentalswallowing assessment techniques. While both toolsrely on perceptual judgements by the assessing clini-cian, they are recognized as complementary bestclinical standards15,36 with acceptable levels of inter-and intra-rater reliability.36 Both tools allow theclinician to trial different food textures, fluid viscosi-ties, compensatory postures, swallowing maneuversand methods of food/fluid presentation to investigatedysphagia presence, profile and the impact of inter-vention. They are useful in providing biofeedback andeducating patients, their families and professionals.36

Studies where VFSS and FEES were both utilized,suggest substantial agreement between the two tech-niques in the detection of laryngeal penetration(k¼0.68, p¼ .000), aspiration (k¼0.75, p¼ .000)and pharyngeal residue (k¼0.67, p¼ .000).37 How-ever, authors report that swallows rated throughFEES received more severe Penetration-AspirationScale scores38 and pharyngeal residue ratings, withpharyngeal residue identified in a greater number oflocations compared to swallows rated using VFSS.39

Videofluoroscopy is a radiological procedure dur-ing which passage of food and fluids coated withradio opaque barium is observed in lateral andanterior-posterior planes. It enables two-dimen-sional visualization of the oral, pharyngeal andupper esophageal phases of swallowing. Potentialrisks associated with VFSS relate to radiation expo-sure40 and the use of contrast material.41

Fiberoptic endoscopic evaluation of swallowinginvolves passing a fiberoptic rhinolaryngoscope con-nected to a camera, light source and video-recordingequipment transnasally, enabling direct visualiza-tion of bolus flow and the surface anatomy ofstructures involved in swallowing.36 Fiberopticendoscopic evaluation of swallowing allows closervisualization of the laryngeal vestibule, vocal foldsand the upper trachea than VFSS, so secretions andbolus residue in or around the upper airway can beexamined, informing judgements on aspiration risk.During peak laryngeal excursion, there is a brief (0.5second) period of ‘‘white out’’36 during which theendoscope view is obstructed by soft tissue structuresat the point of peak pharyngeal constriction. Thepresence of aspiration during ‘‘white out’’ is inferred

by examining material expectorated from the airwayand residue on the subglottic shelf or further insidethe trachea after the swallow.42

Fiberoptic endoscopic evaluation of swallowinghas been used with a variety of clinical adult pop-ulations,43 including patients in intensive care,44,45

with neurological conditions,46-49 head and neckcancer,50 chronic obstructive pulmonary disease51

and muscular dystrophy.52

Risks associated with FEES are minimal for adulthospital inpatients,53-56 and outpatients from hos-pitals53,54,56 or otolaryngology clinics,57 but areaffected by a variety of medical etiologies includingprogressive neurological conditions such as Alz-heimer’s disease.53,54,56,57 Cumulative incidence ofadverse events, including discomfort, epistaxis,vasovagal syncope, self-resolving laryngospasm,gagging, vomiting and mucosal perforation is lessthan one percent according to the largest FEES riskstudy published,56 to the authors’ current knowl-edge. The risk of self-limiting epistaxis may increaseto six percent in acute stroke patients receivingantithrombotic medications.46

More than 50% of adults living in RCFs experi-ence dementia,58 with approximately half of theseadults exhibiting symptomatic agitation.59,60 Severeagitation and a lack of cooperation could provepotentially hazardous during FEES. These factorsare recognized as contraindications that would formpotential barriers to instrumental swallowing assess-ment in some adults with dementia.

Characteristics of FEES that may be valuable in theRCF setting include ease of usage; ability to assesssecretion management without oral intake and beforeonset of severe OD; low cost compared to VFSS; theabsence of radiation exposure, which permits multi-ple and longer assessments when tolerated by thepatient; tool portability, creating potential to performbedside examinations in patients who may not be ableto be moved a different setting; and sensitivity inidentifying bolus spillage, residue and secretions.These characteristics need to be explored in a RCFsetting, to create an evidence-base that can guideclinical decision making in the assessment of OD.

What is not known in residential care facilitypopulations?With projections for accelerated growth in globalaging61 and an increase in the acuity of adults inRCFs,62-64 OD may present significant health




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concerns into the future. Within the field of geriat-rics, there is a focus on minimizing avoidable hospi-tal readmissions, providing quality care inhouse,reducing avoidable hospital transfers63 and optimiz-ing quality of life.

Currently, there is a paucity of research that exam-ines how swallowing is assessed in RCFs and inade-quate data to guide clinical decision making relatingto instrumental swallowing assessment use. Limitedinformation is available throughout a variety of pub-lished and gray literature sources, including internetsites established by mobile FEES service providers inthe US. In this context, a scoping review into the use ofinstrumental swallowing assessments, and specifi-cally mobile FEES and VFS, in RCFs will revealrelevant sources of information, concepts, literaturegaps, searching strategies and obstacles, while inves-tigating the association between concepts, ideas andchallenges in this field.64,65 A preliminary search ofthe JBI Database of Systematic Reviews and Imple-mentation Reports, Cochrane Database of SystematicReviews, CINAHL and PubMed databases on theSeptember 5, 2018, did not reveal any existing scop-ing or systematic reviews on this topic.

The objective of this scoping review is to examineand map available evidence about the use of instru-mental swallowing assessments, specificallyFEES andVFS, in the diagnosis and management of dysphagiafor adults living in RCFs. The frequency of use,acceptability and tolerability associated with instru-ments, as well as barriers and facilitators associatedwith use will be explored. Gaps in the existing evi-dence-base will be identified. Conclusions will bederived about the overall state of research into theuse of this instrumental swallowing assessment tech-nique in residential care facilities. This informationmay help to guide facility managers and speechpathology service providers in developing evidence-based models of instrumental swallowing assessmentfor adults living in RCFs, and identifying adults whomay benefit from these models. It may also provide aplatform for future research into this field.

Review questions

The primary question of this scoping review is: Howare FEES and VFS used to evaluate and manageswallowing for adults in RCFs?

Secondary questions that will also be used tofurther clarify this topic are:

� How are FEES and VFS currently utilized to sup-port dysphagia management in adults in RCFs?

� What factors influence the provision of FEES andVFS in a RCF?

� What is the acceptability and tolerability of FEESand VFS in adults in RCFs?

� Are there differences between and within coun-tries (e.g. across different states or facilities) inthe way that FEES and VFS are accessed andutilized in RCFs?

Inclusion criteria

To maintain congruency between the title, objectivesand questions, the following inclusion criteria for thescoping review will be applied.

ParticipantsLiterature referring to adults who are aged 18 yearsand over will be considered. From 2016 to 2017,adults who are aged 85 years and over comprised53% of people entering permanent RCFs inAustralia66 and the majority of adults in RCFs inthe US.67 Adults over the age of 80 years share anincreased risk of specific comorbidities and geriatricsyndromes that may impact their assessment andcare provision. While less common, young adultswith dysphagia may live in RCFs due to high careneeds resulting from lifelong or acquired conditions(e.g. cerebral palsy, Huntington’s disease or a trau-matic acquired brain injury) and the lack of moresuitable accommodation. Therefore, this scopingreview will consider all adults residing in RCFs.

ConceptIn this review, the focus will be on FEES, one of thetwo most commonly utilized instrumental swallow-ing assessment tools. Fiberoptic endoscopic evalua-tion of swallowing is recognized as the best clinicalstandard, complementary to VFSS.

ContextA RCF is a place that offers 24-hour care, includingnursing care, to adults who require assistance withmedications, medical care or activities of daily livingdue to physical, cognitive or emotional challenges.Alternate names utilized in the literature and there-fore included in this scoping review are: residentialcare,68 care facility,35 long term care,63 care home,69

skilled nursing facility,63 nursing home,17 nursingfacility63 and assisted living.17




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Types of sourcesTo capture the full breadth of published and unpub-lished evidence on instrumental swallowing assess-ment in RCFs, literature written in English from2000 to present in textbooks, peer reviewed jour-nals, gray literature, editorials and theses will beincluded. The period selected correlates with thepublication of a comprehensive textbook aboutFEES,70 now widely referenced, the emergenceand acceptance of FEES as an established instrumen-tal swallowing assessment tool, and the gradualincrease in the use of FEES in certain countries.

Methods

This scoping review will be performed and reportedusing JBI methodology for scoping reviews.71

This protocol was developed to provide transpar-ency on the review process and minimize reportingbias. The JBI methodology aligns itself with Pre-ferred Reporting Items for Systematic Reviews andMeta-Analyses (PRISMA) and Enhancing the Qual-ity and Transparency of Health Research (EQUA-TOR) principles to standardize the process forconducting and reporting scoping reviews.71-73

Search strategyA three-step, iterative search strategy will beemployed, as advocated by the JBI scoping reviewmethodology.71,72

Step one will include an initial limited search ofthree online databases, specifically MEDLINE,CINAHL and Embase, using the search terms in

Table 1. Search terms were derived from the con-cepts in the title of the scoping review and refined.

The titles, abstracts and index terms of relevant,retrieved literature will be analyzed to create aninventory of search terms. A research librarian willbe consulted during this process to ensure that thesearch terms have been refined appropriately.

Step two will involve a search across online data-bases, using the established inventory of searchterms. An example search strategy for CINAHL isprovided in Appendix I. This scoping review encom-passes topics relevant to medicine (e.g. endoscopy,pneumonia), economics (e.g. cost of hospital read-missions) and allied health sciences (e.g. swallowingassessment). Therefore, a range of databases wasselected to cover these fields.

Gray literature searching will also be conductedto avoid publication bias and because preliminarysearches have suggested a paucity of publishedresearch data. Relevant material captured by thestep two search will be identified.

Step three will include a search of reference lists ofall papers included in the review for additional,relevant studies based on information contained intheir titles and abstracts. The primary reviewer willcontact the authors for further information, whennecessary.

Information sourcesThe databases to be searched include: MEDLINE,CINAHL, Embase, Scopus and Cochrane Databaseof Systematic Reviews.

Table 1: Search strategy terms

Population Concept Context

1 2 3 4 5

adult� OR elderlyOR older person�

OR frail OR dis-abled OR demen-tia OR�alzheimer’s dis-ease OR geriatric

swallow� ORdeglutition ORaspirat� ORchok� OR�pharyngeal ORdysphagi�

assess� OR diagnos�

OR screen OR ana-lys� OR measure�

OR evaluat� ORrehabilitat� ORtreat� OR therap�

OR practicepattern� OR�practice OR mal-practice OR man-age�

instrument� OR FEESOR FEESST ORfibreoptic endoscopicevaluation of swallow-ing OR fiberopticendoscopic evaluationof swallowing�endoscop� ORlaryngoscop� ORvideofluoro� OR VFSOR VFSS

residential careOR care facilityOR skilled nurs-ing facility ORlong term careOR nursing homeOR care homeOR institution�




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Gray literature sources will include: GoogleScholar; Google (advanced search); position papersof national speech pathology professional bodies incountries where FEES is utilized; position papers ofthe European Society of Swallowing Disorders; bookchapters in selected speech pathology textbooks (e.g.Endoscopic Evaluation and Treatment of SwallowingDisorders); websites of mobile FEES service pro-viders; and dissertations published in English fromOpen Access Theses and Dissertations, DART –Europe e-Theses Portal, ProQuest Dissertations andTheses Global, and British Library Electronic ThesesOnline Service.

Study selectionAll citations and articles retrieved during the searcheswill be imported into EndNote reference managementsoftware (Clarivate Analytics, PA, USA). The soft-ware will enable duplicate citations to be identifiedand removed. Relevant articles will then be importedinto Rayyan (Qatar Computing Research Institute,Doha, Qatar), a web and mobile software applicationfor systematic reviews, created to enhance datascreening and collaboration between reviewers.

Two reviewers will screen the titles and abstractsof articles and other literature, retrieved in steps twoand three of the search process against predefinedinclusion criteria (Appendix II). Full texts will beretrieved and screened, when inclusion criteria aremet or if there is ambiguity about the inclusion of aparticular study in the review. If a discrepancy injudgment arises between the two reviewers andcannot be resolved through discussion, a third inde-pendent reviewer will examine the full text of thearticle and make the final decision.

Data extractionA draft charting form has been developed to recordkey information extracted from the selected full textarticles (Appendix III). This form will capture thefollowing information: author(s); year of publication/completion for unpublished data; country of origin;source category; population/ sample size; methodol-ogy; intervention type; outcomes; key findings and/orcontentions about i) instrumental swallowing assess-ment in adults in RCFs, ii) VFSS in adults in RCFs, iii)FEES in adults in RCFs; current authors’ intention tocontact the author(s) of the article.

Inter-rater reliability of the charting form will beoptimized by randomly selecting 10% of articles for

two independent researchers to review. Informationextracted will be compared to ensure consistencyand alignment with the objective/questions of thisscoping review. As recommended in the JBI scopingreview protocol, the charting table will then bemodified to capture any additional informationidentified as relevant by the reviewers.71,72 Theremaining articles will be reviewed and data willbe extracted by the primary reviewer.

Data presentationA PRISMA diagram will be used to graphicallyrepresent the flow of information through stepstwo and three of the search strategy, and throughstudy selection.73 The diagram will depict recordsidentified, included, excluded and the rationalefor exclusion.

Key findings of data extracted and their relation-ship to the research questions will be summarized ina chart. A discussion and interpretation of theseexploratory findings for advancing current under-standing of instrumental swallowing assessment inadults in RCFs will be presented in narrative form.

Acknowledgments

The authors would like to thank Lindy Cochraneand Tania Celeste, librarians from the University ofMelbourne, for their advice and support in formu-lating the search strategy for this paper.

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Appendix I: Example of tier two in the search strategy

CINAHL database

Search conducted: September 9, 2018

Search No. Query

S1 TI dysphagia AND TI (residential care OR care facility OR skilled nursing facility ORlong term care OR nursing home� OR care home OR institution�) AND SU deglutitiondisorders

S2 TI (Videoendoscop� OR instrument� OR FEES OR FEESST OR fibreoptic endoscopicevaluation of swallowing OR fiberoptic endoscopic evaluation of swallowing ORvideofluoro� OR VFS OR VFSS) AND TI swallow� AND AB (residential care OR carefacility OR skilled nursing facility OR long term care OR nursing home� OR care homeOR institution�)

S3 TI dysphagia AND TI practice pattern�

S4 SI OR S2 OR S3

Limited to 2000-present; English language




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Appendix II: Inclusion criteria

Participants Concept Context Sources

Adults who are 18years and over

Fiberoptic endo-scopic evaluation ofswallowing andVideofluoroscopySwallowing Study

Residential carefacility

Literature written in English from2000 to present in: textbooks, peerreviewed journals, gray literature,editorials and theses.




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Appendix III: Data extraction tool

Article ID No:

Author(s):

Country of origin:

Published (including year of publication) or gray literature:

Source:

Aims:

If research methodology utilized Population/sample size:

Design and methodology:

Intervention type:

Outcomes/details:

Key findings/contentions about:

i. Instrumental swallowing assessment in adults in RCFs:

ii. VFSS swallowing assessment in adults in RCFs:

iii. FEES in adults in RCFs:

Author contact indicated (Y/N):

FEES: fiberoptic endoscopic evaluation of swallowing; RCF: residential care facility; VFSS: videofluoroscopy swallowing study.




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