Modified Barium Swallow Study……Part 2

I was recently directed to a blog post by Clinical Colleagues Confidential. regarding Modified Barium Swallow Studies (MBSS).

The title of the blog post is:

I have all the answers but nobody is asking me any questions


The original blog post can be found at:  http://cccslp.net/whats-the-frequency-3/

This is part 2, because I recently wrote a post about MBSS.

Being an SLP that actually completes MBSS, I felt I needed to address some of these issues comments.

1) I stopped the MBS because I was afraid the patient would aspirate.  Patients aspirate……it happens.  They have probably been aspirating for a long time prior to your study.  If you are afraid of aspiration, how can you assess the patient’s true swallow function?

2) The patient was coughing so I changed him to pudding at bedside.  Patients cough.  You need to check the patient’s meds (some actually cause a cough) and trial a consistency more than once to determine if the consistency is causing the cough.  It is also helpful if you use an instrumental exam such as FEES or MBSS to determine the physiology of the swallow.

3) I didn’t try thin during the MBS because at the nursing home he was already on nectar so I started there.  I use the protocol employed by the MBSImP.  Thin is tested.  I don’t stray from my consistencies.  I use thin, nectar, pureed and cookie with every patient (unless there is a very valid reason to not do a certain consistency).
There are many pieces of information you can use when you assess thin that you don’t get from nectar.  That’s why I don’t skip it.

4) There’s no speech at nursing homes so I put her on the safest diet; puree and pudding thick.  Who says that pureed and pudding thick is the safest.  Sometimes thick is not necessarily better.  Many people eat safely, millions in fact without the presence of speech.  You should not punish your patient because of lack of SLP.

5) A suspected timing delay of the epiglottis might be present and could lead to aspiration even though none was apparent on the MBS but to be safe I recommend nectar thick liquids.  If you did the MBSS, you should know if there is a delay of the epiglottis or not.  You SHOULD be assessing the epiglottis.  You should also know that epiglottic movement is indicative of hyolaryngeal excursion.  Sometimes you don’t see aspiration on the MBSS but you should be looking at airway protection and hyolaryngeal excursion which is an indicator.

6) I didn’t want to recommend something they might aspirate and get sued.
I wish there was no number 6. Sadly, I think it is the driving force behind many of the recommendations. But, I would spread some words of caution to my peers, especially the younger ones. The only thing that avoids litigation is luck. The thing that wins litigation is expertise and documentation.
If you make a swallowing recommendation in isolation of the needs of whole patient to save him from aspiration pneumonia and he goes into renal failure…that’s a big problem.  I agree….documentation is key.  If you document that the patient appears safe, that is your finding.  You should be confident in your skills and you should be effective in your skills in completing MBSS.  This is not an area we can make a mistake because that can put your patient at high risk for pneumonia, respiratory issues, maybe death.  You recommend what’s appropriate for that patient without worry about litigation.

We seriously need to take a look at our profession.  WE are the experts in dysphagia.  We need to demonstrate our skills as experts.  Dysphagia is not an area we can “tinker” in.  

I highly recommend that any SLP completing MBSS that has made any of the above statements, take the Modified Barium Swallow Impairment Profile (MBSImP) by Bonnie Martin Harris.  This is becoming the gold standard for standardization of modifieds.  

Our responsibility as SLPs completing MBSS is to determine the physiology and etiology of the swallow/dysphagia.  We need to determine what is functioning and what is not functioning in the oropharyngeal mechanism.  Our job is not to state aspiration or penetration or….I coulnd’t do that because I was scared of this.  Our job is to state epiglottic dysfunction, lingual dysfunction, decreased laryngeal elevation, decreased arytenoid movement, and so on.  

SLPs need to take a stand and become experts in the area of dysphagia.

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