Visual Analysis of Swallowing Efficiency and Safety (VASES)

Below is a video recording of a VASES training seminar that was completed internally for a small group of colleagues and trainees. The goal of the training seminar (2 hours, 35 minutes) was to equip attendees with the foundational skills to begin to use VASES in clinical practice.  Specifically, this training seminar covers: (1) orientation to anatomy as seen on FEES; (2) reviewing the 'Where' (anatomic boundaries), "When' (temporal phases'), 'What' (VASES ratings), and 'How' (rating methodology) of VASES, along with its miscellaneous/secondary rules; (3) how to use recently published VASES  normative data to aide in interpretation of VASES ratings; and (4) 20 minutes of calibration practice with FEES videoclips. 

Archive of previous trainings:

2021-08-25 (initial training webinar)

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.

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.

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:

When describing pharyngeal residue...

Instead of saying: "Patient presents with a moderate amount of vallecular residue with pudding boluses following a single swallow cue. This cleared to trace amounts following 2-3 extra swallows"...

Try saying: “Patient presents with about 40-50% of the valleculae being filled with oropharyngeal residue following a single swallow cue. This cleared to ~5-10% filling following 2-3 extra swallows.” 

When describing penetration...

Instead of saying: "Patient presented with intermittent penetration into the vestibule but remaining the vocal folds with thin liquids"...

Try saying: “Patient presented with intermittent penetration into the vestibule but remaining above the vocal folds with thin liquids. When present, penetrant residue covered about 30-40% of the laryngeal vestibule.” 

When describing aspiratiom...

Instead of saying: "Patient presented with intermittent aspiration with thin liquids, with two events of silent micro amounts of aspiration and one event of non-silent gross amount of aspiration"...

Try saying: “Patient presented with aspiration on 3 of the 10 thin liquid trials. Two aspiration events were silent, with residue covering approximately 2-10% the subglottic shelf, and one aspiration was non-silent, with residue covering approximately 40% of the subglottic shelf.”

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.

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 can be integrated as an outcome measure 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. Penetration-Aspiration Scale (PAS)

   • • Two PAS ratings should be made for each swallowing trial: PAS-swallow and PAS-between. PAS-swallow is a singular PAS score given for what happened before, during, and after the swallow. For PAS-swallow, a clinician can use the temporal boundaries to indicate the first point in time when airway invasion occurred (e.g., PAS 3 during the swallow). PAS-between should used to represent what occurred between bolus trials. The maximum between PAS-swallow and PAS-between should be used to report what occurred for that particular trial.   

     • PAS should be “1” by default for PAS-swallow and PAS-between. PAS changes from 1 only when there is change in bolus flow or ejection effort. Examples:

       1. If a patient demonstrates a PAS 3 during the swallow, and the laryngeal vestibule residue remains in the laryngeal vestibule between bolus trials and does not spill further down onto the vocal folds or into the subglottis, then the patient would have a PAS 1 for between bolus trials. A PAS of 3 would be given for this swallow since it is the higher of the two PAS scores.

       2. If a patient demonstrates a PAS 3 during the swallow, and the laryngeal vestibule residue is ejected out of the laryngeal vestibule between bolus trials, then the patient will have a PAS 2 for between bolus trials. A PAS of 3 would be given for this swallow since it is the higher of the two PAS scores.

       3. If a patient demonstrates a PAS 3 during the swallow, and the uncleared laryngeal vestibule residue spills onto the vocal folds but not into the subglottis between bolus trials, then they would have a PAS 5 for between bolus trials. A PAS of 5 would be given for this swallow since it is the higher of the two PAS scores.

       4. If a patient demonstrates a PAS 8 during the swallow, and then the patient coughs between bolus trials but residue remains in the subglottis, then the patient would have a PAS 7 for between bolus trials. A PAS of 8 would be given for this swallow since it is the higher of the two PAS scores.

       5. If a patient demonstrates a PAS 7 during the swallow, and the aspirate residue remains in the subglottis between bolus trials, then the patient would have a PAS 1 for between bolus trials. A PAS of 7 would be given for this swallow since it is the higher of the two PAS scores.

       6. If a patient demonstrates a PAS 7 during the swallow, and then new residue spills into the subglottis between bolus trials without a cough or throat clear response, then the patient would have a PAS 8 for between bolus trials. A PAS of 8 would be given for this swallow since it is the higher of the two PAS scores.

     • Penetration and aspiration should be judged to have occurred 'during' the swallow when residue is observed within the larynx or subglottis and both of the following are present: (1) there was no observable airway invasion 'before' the swallow; and (2) when there was no observable change in airway-related bolus flow in the "after the swallow" or "between bolus trials" temporal boundaries.PAS scores change across temporal boundaries only if there is a change in bolus flow from one anatomic boundary into another, or the presence of an ejection effort response to new bolus flow. 

1. Curtis, J.A. , Borders, J.C., Dakin, AE., Troche, M.S. (2023). Normative Reference Values for FEES and VASES: Preliminary Data from 39 Non-Dysphagic, Community-Dwelling Adults. Journal of Speech, Language, and Hearing Research (JSLHR). DOI: 10.1004/2023_JSLHR-23-00132

2. 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

3. 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

4. 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.

5. 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.

6. 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.