Instrumental assessments are always a hot topic on social media. For many years now the Modified Barium Swallow Study (MBSS) also known as Videofluoroscopic Swallow Study or the Cookie Swallow, has been considered the gold standard for dysphagia assessment. Flexible Endoscopic Examination of Swallowing (FEES) has become increasingly more popular and utilized, but for the purposes of this post only the MBSS will be discussed.
Why are we only looking at Aspiration and Penetration?
Often the reason for completing a Modified Barium Swallow Study is to determine the “presence of aspiration and to choose the most appropriate diet for the patient.” An MBSS should be completed to assess the anatomy and physiology of the swallow to determine the appropriate treatment plan. When the SLP evaluates a patient clinically, once that patient closes the mouth we can only infer what is happening. We may have a good judgement, however an instrumental assessment can confirm or deny that judgement.
Not only does the MBSS confirm the anatomy and physiology, but should also be used to determine the effectiveness of compensatory strategies such as a chin tuck or head turn. You can also view the effects of NMES (Vitalstim, Ampcare, eSwallow, Guardian) on the swallow with the MBSS. For example, how do you know the Mendelsohn is effective or that the patient is even completing it in the correct manner if you haven’t viewed it under fluoroscopy?
Dr. Jeri Logemann described the Modified Barium Swallow Study as having a primary purpose to determine the presence and reason for aspiration as a basis for treatment. (Logemann, Jeri A., and Jeri A. Logemann. “Evaluation and treatment of swallowing disorders.” (1983): 210.)
Dr. Logemann has set a protocol for administration of barium as 2 swallows of each: thin liquids (1 ml, 3 ml, 5 ml, 10 ml, and cup drinks), pudding and 1/4 of a Lorna Doone cookie with barium. (Logemann, Jeri A. Manual for the videofluorographic study of swallowing. Pro ed, 1993.)
The MBSS is used for more than determining a diet level.
The MBSS is not meant to test every consistency available. It is often referred to as a “moment in time” or “not realistic to everyday consumption of a patient.” The MBSS is meant to be a measure of the swallowing physiology, not a test of every consistency the patient may or may not consume. Fatigue can be addressed during the swallow study by turning off the fluoro after the initial swallows, allowing the person to eat or drink and then continuing the fluoro.
In an article by Robbins et al, “The modified barium swallow permits direct observatino of oropharyngeal behavior and bolus transit from the oral cavity through the cervical esophagus during swallowing.” (Robbins, Jo Anne, et al. “A modification of the modified barium swallow.” Dysphagia 2.2 (1987): 83-86.)
The Modified Barium Swallow Impairment Profile (MBSImP) defines 17 components of the swallow as listed below. The protocol includes trials of thin liquids, nectar thick liquids (via tsp, cup and/or straw with a cued swallow and spontaneous swallow), pudding and cookie/cracker. You can test other consistencies but it was determined through research that these consistencies may be enough for most patients. Nectar thick liquids are assessed even in the absence of penetration/aspiration of thin liquids as the structural movements may increase with the thicker consistency liquid. (Martin-Harris, Bonnie, et al. “MBS measurement tool for swallow impairment—MBSImp: establishing a standard.” Dysphagia 23.4 (2008): 392-405.)
17 Components of the Swallow:
1. Lip Closure
2. Tongue Control During Bolus Hold
3. Bolus Preparation/Mastication
4. Bolus Transport/Lingual Motion
5. Oral Residue
6. Initiation of the pharyngeal swallow
7. Soft Palate Elevation
8. Laryngeal Elevation
9. Anterior Hyoid Excursion
10. Epiglottic Movement
11. Laryngeal Vestibular Closure
12. Pharyngeal Stripping Wave
13. Pharyngeal Contraction
14. Pharyngoesophageal Segment (PES) Opening
15. Tongue Base Retraction
16. Pharyngeal Residue
17. Esophageal Clearance
Please don’t stop with aspiration.
Often MBS Studies are discontinued because the patient aspirates. This should be the time you trial compensations and strategies to stop aspiration. This study probably isn’t the first time the patient aspirated. They are coming in for a swallow study aren’t they? It is your job to determine why they are aspirating and how to stop it.
Communication is key.
As the treating SLP, it is so important to get information to the SLP completing the instrumental assessment regarding patient history, why you are ordering the study and possibly even some information about your tentative treatment plan, current diet level, etc. Most patients are not able to relay the information the same way an SLP would, if at all.
As the assessing SLP or the SLP completing the instrumental assessment, it is critical that the treating SLP receive a report they can use to build a treatment plan. It is impossible to educate a patient on why they are on an altered diet or why they need to use such and such compensation when the SLP is unsure. The report needs to include compensations trialed and effective or ineffective. It’s also very difficult to know what consistencies, amounts, etc to use for therapeutic trials if the study was discontinued after one instance of aspiration on a teaspoon of thin.
You won’t get an instrumental assessment if you don’t request it.
Often instrumental assessments are not recommended for a variety of reasons. Maybe you have sent multiple patients out for an MBSS and the report is not what you need to create a solid treatment protocol. Maybe the patient refuses or the doctor refuses or the facility refuses.
It is time that we educate physicians, nurses and other medical professionals on the purpose of the MBSS. Physicians often know or have a good idea that a patient had a stroke. They still use the CT scan and/or MRI to determine size of stroke, location of stroke and whether the stroke is acute or an old infarct. We need the same diligence in our field to assess dysphagia beyond just penetration/aspiration and diet selection. Whether the physician orders the MBSS or the patient participates should be irrelevant to our recommendation for MBSS. If we believe the MBSS is an important tool to our patient’s care, document and recommend.