Visual Analysis of Swallowing Efficiency and Safety (VASES)

Visual Analysis of Swallowing Efficiency and Safety (VASES) is a standardized approach for rating pharyngeal residue, penetration, and aspiration during FEES. It establishes clearly defined anatomic and temporal boundaries within which to rate functional swallowing outcomes. VASES is intended to increase the transparency, sensitivity, reliability, and generalizability of FEES ratings and analysis for clinical and research purposes. For written instructions on how to interpret FEES using VASES, please refer to the original publication (copy-edited version; free self-archived version) and the free supplemental training document to learn more. After you have read the aforementioned material, you may consider viewing the below videos.

VASES Training Webinar

Below is a video recording of a YouTube live stream webinar event. This VASES training webinar was given online, for free to the public on August 25th, 2021. Feel free to view the below recording and share it with others as you begin to train your FEES interpretation skills using VASES.

How to Use VASES in Clinical Practice

Ideally, each bolus that is part of your standardized FEES protocol should be rated using VASES. However, as you first begin to use VASES and balance FEES interpretation with workflow, you may consider starting off with rating just one swallowing condition (e.g., all trials of a patient preferred volume of thin liquid cup sips) or one trial for each swallowing condition (e.g., the first trial of each bolus volume and consistency). As you get faster and more efficient with ratings, you should consider rating every swallowing trial. On average, it is estimated that rating all seven outcome measures with VASES will take ~1 minute to complete. See the below video of me interpreting a FEES video clip using VASES using an (older version) unofficial VASES scoring sheet. Note that the time to rate the video clip is less than two minutes when including the viewing time of the entire video clip ~1 minute when considering only the amount of time it took to rate VASES.

To assist with rating FEES using VASES and writing up reports, you may consider downloading an unofficial VASES scoring sheet (updated February 20th, 2022) and a written report FEES template (uploaded March 15th, 2022). Just click File > Download. Check back periodically for updates as errors and modifications are inevitable.

Below is a 60-minute video where I review with some graduate interns that I am supervising how to use the unofficial scoring (developed October 2021). In the video, I also review the anatomic and temporal boundaries of VASES. Please note that views expressed during this video are my own, as I am casually discussing FEES interpretation with graduate interns that I am training.

Interpretation Practice

Below is a video you can use to further practice FEES interpretation using VASES. In this video, you will hear a few graduate students, who are relatively new to VASES, and myself talk discuss VASES ratings for several FEES video clips. This was recorded in October 2021 immediately after the "VASES Unofficial Scoring Sheet Overview" video above. Be aware that typical VASES rating goes much quicker, but that the ratings in this video are much slower to allow for discussion with the trainees. Also note that views expressed during this video are my own, as I am casually discussing FEES interpretation with graduate interns that I am training.

VASES Updates

The following are updated/additional VASES rules not previously outlined in the original VASES manuscript. Last updated January 30th, 2022.

  1. For all anatomic landmarks

      • If absolutely no view of a certain structure, then keep it blank. However, if you see even a partial view, rate what you see. Rate the amount of residue seen, expressed as a percentage of visualized and non-visualized anatomic area

  2. For vocal fold residue:

      • Rate residue relative to the superior surface of the membranous vocal folds

      • Vocal fold residue can be greater than 100 (e.g., if entire superior surface is covered and medial edges are covered)

  3. For subglottic residue:

      • Residue ratings can be greater than 100 (e.g., if entire subglottic shelf is covered and residue is also seen in the trachea)

  4. Bolus location at swallow onset

      • Bolus location at swallow onset is a new outcome measure that can be integrated using anatomic and temporal boundaries outlined by VASES.

      • For bolus location at swallow onset, indicate each and every anatomic landmark containing the bolus at the onset of "during" the swallow. This means, more than one anatomic landmark may be selected. As with all VASES outcomes, the bolus should be directly observed in/on the anatomic boundary, and not inferred.

      • As a standard rule, if patient does multiple swallows, then use the first swallow to describe bolus location at swallow onset. This may be adjusted to describe each swallow, if desired.

      • If the onset of “during the swallow” is not observed due to whiteout, then do not rate bolus location at swallow onset

  5. PAS ratings should be made for each of the four temporal boundaries.

      • The max PAS across these boundaries could used if desiring only one PAS rating per swallow.

      • PAS scores for “during” the swallow can (and likely will) be judged by what is seen “after/between.” This should be done if there is no observable change in airway-related bolus flow in the "after the swallow" or "between bolus trials" temporal boundaries.

      • PAS scores should be “1” by default

      • PAS scores do not get repeated across temporal boundaries without a change in bolus flow or ejection effort. For example if a patient demonstrates a PAS 3 during the swallow with no changes "after" or "between", then the patient will have a PAS 1 for after and between. Only in instance where more events of penetration into the vestibule without ejection are observed, perhaps from pharyngeal residue, would a patient get another PAS 3 after or between.

      • PAS scores change across temporal boundaries only if there is a change in either bolus flow from one anatomic boundary into another, or the presence of an ejection effort response to new bolus flow.

      • Rate what you see. For example, if penetration into the vestibule was observed "before", and subglottic aspiration was observed immediately after (presumable occurring "during"), then the patient will have had PAS 2-3 "before, and PAS 6-8 "during", pending on ejection response.

      • Example PAS Scoring Scenarios:

        1. If penetration to the vocal folds occurred “during” the swallow with residue remaining on the vocal folds “after” the swallow and “between bolus trials”, then PAS ratings would be 1 (before), 5 (during), 1 (after), and 1 (between)

        2. If penetration to the vocal folds occurred “during” the swallow, with the vocal fold residue spilling into the subglottis “after” the swallow with no effort to eject, and residue remaining in the subglottis “between bolus trials” with no effort to eject, then PAS ratings would be 1 (before), 5 (during), 8 (after), and 1 (between)

        3. If penetration to the vocal folds occurred “during” the swallow, with the vocal fold residue spilling into the subglottis “after” the swallow with no effort to eject, and residue remaining in the subglottis “between bolus trials” with an eventual effort to eject in this temporal boundary, then PAS ratings would be 1 (before), 5 (during), 8 (after), and 7 (between)

        4. If penetration to the vocal folds occurred “before” the swallow, with continued penetration of more bolus to the vocal folds “during” the swallow, and with the vocal fold residue spilling into the subglottis “after” the swallow with no effort to eject, and residue remaining in the subglottis “between bolus trials” with an effort to eject, then PAS ratings would be 5 (before), 5 (during), 8 (after), and 7 (between)


References

  1. Curtis, J.A., Borders, J.C., Perry, S.E., Dakin, A.E., Seikaly, Z.N., Troche, M.S. (2021). Visual Analysis of Swallowing Efficiency and Safety (VASES): A standardized approach to rating pharyngeal residue, penetration, and aspiration during FEES. Dysphagia. DOI: 10.1007/s00455-021-10293-5

  2. Curtis, J.A., Borders, J.C., Troche, M.S. (2022). Visual Analysis of Swallowing Efficiency and Safety (VASES): Establishing Criterion-Referenced Validity and Concurrent Validity. American Journal of Speech-Language Pathology. DOI: 10.1044/2021_AJSLP-21-00116