Modified Barium Swallow Study: Gold Standard or Old News?

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.


5 thoughts on “Modified Barium Swallow Study: Gold Standard or Old News?

  1. What a great post. It has been nearly 30 years since I first walked into a flouro suite in a large teaching hospital with the goal of educating a radiologist about why a speech-language pathologist should be in radiology performing a procedure.

    Throughout that time span, I have worked with a handful of interested radiologist, and also some who prefaced the study by saying” I hate doing these things.”

    Over the same 30 years, the field of dysphagia has grown tremendously, our knowledge base via research and clinical practice seems to provide new information almost weekly, and yet, as a profession, we seem to still fuss with the same issues, including support for the SLP’s referral for an instrumental exam when warranted.

    I have the opportunity to work with a colleague who performs mobile MBS exams. Following completion of the study, I am able to review the video with my patient/s as often as needed, describe and discuss what the findings represent, and offer a rationale for treatment recommendations. I have found this moment to be crucial to goal setting and patient adherence.

    Hopefully, young clinicians armed with even more of a knowledge base than I had 30 years ago, will follow the advice you put forward in your post, and not yield to the various outside pressures to provide any less than is appropriate to the patient’s under our care.

  2. Holly says:

    This is a fantastic article. The MBSS is only as good as the SLP, in terms of knowing all the areas/functions to address during the MBSS (lip closure, lingual involvement, etc)
    Also, FEES has been very difficult for the population I work with (dementia). Its noxious, they do not understand the components of the assessment. The MBSS is stressful enough, but they only have to “eat”, therefore, the MBSS has been my choice for many years.

  3. Beach sandals says:

    I appreciated article very much and agree with your viewpoint. Sadly, some large acute care hospitals are so fast-paced that there is pressure to complete the studies quickly. They leave no time to explore compensatory strategies. I really like the idea of mobile MBS. I will look into that!

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