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. Note: some updates have been made to VASES which can be found at the bottom of this page, based on clarifying questions I have received over recent years.
Additional 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 - some updates have been made since. Please be aware that VASES ratings typically goes much quicker (especially after some VASES rating experience), but that the ratings in this video are much slower to allow for discussion with 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.
Providing VASES Ratings in Clinical Practice
Ideally, each swallowing trial 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 clinical workflow, you may consider starting off with rating only select standardized swallowing trials. As you get faster and more efficient with VASES 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. The video below include interpretation of a FEES video clip with VASES using an older version of an unofficial 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, you may consider downloading an unofficial VASES scoring sheet (updated August 12th, 2023). Just click File > Download. Check back periodically for updates as errors and modifications are inevitable.
Below is a 60-minute video that you can view for additional interpretation practice. In this video, I 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.
Report Writing and Clinical Language
From a spoken language perspective, VASES results is relatively easy to discuss when speaking with colleagues. Simply replace the subjective categorical terms we as clinicians are typically used to using (e.g., mild, moderate, severe, micro (aspiration), gross (aspiration), etc.) with the percentage-based ratings. For example:
From a report writing perspective, you may consider downloading a written report FEES template (uploaded August 12th, 2023). Just click File > Download. Check back periodically for updates as errors and modifications are inevitable.
Preliminary normative data are available from 39 community dwelling adults (see reference below and the 'Free Publications' section of this website). Clinicians can use these preliminary reference values to characterize how typical vs atypical a patient is present when compared to non-dysphagic, community-dwelling adults.
VASES is used to rate functional swallowing swallows at the trial level. While this increases the transparency and standardization of FEES interpretation, it does not facilitate judgements of overall impairment. DIGEST-FEES, originally published in 2021 by Starmer and colleagues, fills this important clinical gap. DIGEST-FEES uses trial-level ratings of swallow function to generate protocol-level impairment 'grades' in swallowing safety, pharyngeal swallowing efficiency, and overall pharyngeal swallow function. DIGEST grades include 0 (no impairment), 1 (mild impairment/mildly atypical), 2 (moderate impairment/moderately atypical), 3 (severe impairment), and 4 (profound impairment). DIGEST-FEES was adapted from DIGEST, originally developed by Hutcheson et al. in 2017, with a revised version (DIGEST version 2) published in 2022. Interested clinicians should read these articles (references below) to learn more.
The current practice pattern of myself, my colleagues, and the trainees with whom I mentor is to rate all swallows within a standardized FEES protocol using VASES, and then use these VASES ratings to derive DIGEST-FEES grades. As part of DIGEST-FEES, trial-level ratings of pharyngeal residue must identified. VASES subdivides pharyngeal residue ratings into oropharyngeal residue and hypopharyngeal residue. Therefore, in order to create a pharyngeal residue for DIGEST-FEES, our current practice pattern is to use the maximum rating between the oropharynx and hypopharynx.
Additionally, at our center, we have altered the DIGEST-FEES grading terminology associated with grades 1 and 2 from 'Mild Impairment' and 'Moderate Impairment' to 'Mildly Atypical' and 'Moderately Atypical'. The choice was made to do this after our team used the currently available VASES norms to identify the frequency of that DIGEST-FEES grades would have been observed using our current standardized protocol. However, using these terms deviates from DIGEST-FEES, and therefore, should be done with caution and careful consideration.
The following are updated/additional VASES rules not previously outlined in the original VASES manuscript. Last updated January 30th, 2022.
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
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
Starmer, H. M., Arrese, L., Langmore, S., Ma, Y., Murray, J., Patterson, J., ... & Hutcheson, K. (2021). Adaptation and validation of the dynamic imaging grade of swallowing toxicity for flexible endoscopic evaluation of swallowing: DIGEST-FEES. Journal of Speech, Language, and Hearing Research, 64(6), 1802-1810.
Hutcheson, K. A., Barbon, C. E., Alvarez, C. P., & Warneke, C. L. (2022). Refining measurement of swallowing safety in the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) criteria: Validation of DIGEST version 2. Cancer, 128(7), 1458-1466.
Hutcheson, K. A., Barrow, M. P., Barringer, D. A., Knott, J. K., Lin, H. Y., Weber, R. S., ... & Lewin, J. S. (2017). Dynamic Imaging Grade of Swallowing Toxicity (DIGEST): scale development and validation. Cancer, 123(1), 62-70.