Modifieds……The Who, What, When, Why and How

The Modified Barium Swallow Study

The Modified Barium Swallow Study or MBSS is an assessment to determine the physiology of the swallow.   

The MBSS is often ordered to “determine what consistency is the safest” or to “rule out aspiration” however there is so much more we can discover with the MBSS.

The MBSS is to confirm the diagnosis of dysphagia.  Not only to confirm the dysphagia but to also determine the cause of the dysphagia.

Do you often wish you had a nickel for every time you suspected a dysphagia and it was really something else?  Or that you suspected a normal swallow that was actually a dysphagia?   I would be retired by now!

The thing is, we can’t do instrumentals on absolutely every person that we see.   It would be nice, but it’s not always reasonable.

We have to determine when instrumental is important.

The Who 

So, let’s begin with the who.  Who is appropriate for an MBSS?  When I am contemplating an MBSS for a patient I look at the following:

 1.  Are they appropriate for an MBSS??  They have to have some level of consciousness, it helps if the patient can follow simple directions (for chin tuck, swallow, etc), but they don’t HAVE to be able to follow directions.  It does help if they are able to sit up.  It is extremely difficult, though not impossible, to view what you need to view with someone that is constantly slumped over.  

 2.  Will this MBSS change my plan of action?  If the MBSS will not change any part of the plan of treatment, it may be unnecessary.  If I am looking at treatment planning and compensation/maneuver assessment, then, yes, this person is in need of an MBSS.

 3.  To some degree we need to evaluate the physical status of the patient.  If you have had the luxury of looking at the fluoro machine, there is not a lot of space for the patient to sit in the machine.  Some people just don’t fit in the machine and if we squish them in the space, their shoulders hunch up to a point it’s difficult to examine the patient.  This problem can be overcome however with use of the C-arm, which is a large C shaped machine that ANY patient could sit inside.  The only reason that some x-ray techs and radiologists don’t like the C-arm is because it has increased fluoro exposure and can be difficult to move.

The What 

What does an MBSS tell us?  

An MBSS is used to tell us a large variety of information, not only to detect the presence or absence of aspiration.  When we are completing an MBSS, we should be looking at muscle movement throughout the swallow including pharyngeal stripping wave, tongue base retraction, hyolaryngeal excursion, etc.  

With hyolaryngeal excursion, you are examining the movement of the arytenoids, the laryngeal closure and laryngeal excursion.  

An MBSS tells us what physical aspects accompany a “silent” aspiration and what compensations may work for or worsen the swallow.  If you use a treatment approach such as McNeill Dysphagia Therapy Program (MDTP), you are also looking for your starting point for therapy.

The When 

When is a patient appropriate for an MBSS?  As I’ve stated above, a patient needs to be able to have some ability to follow simple directions (even as simple as open your mouth) and should be able to sit upright, even if it is with support.  

There are times with ICU patients, they are just not quite medically stable to be moved down to the x-ray suite and/or tolerate the procedure.  Also, consider, if the person has JUST had a stroke, they may need a day or 2 to recover prior to the MBSS.  If they’ve just had their trach pulled or have been extubated, they may need some recovery time prior to the MBSS, however that is very much dependent on each patient.

The Where  

The where is the fluoroscopy suite, if you are in a hospital setting.  If you’ve never been in one, you really need to make a visit.  The fluoro suite (any that I’ve been in) is somewhat small.  The patient is sat on a special chair (a Hausted chair for me) and is between the fluoro table and tube.  The radiologist will push the pedal/button to fluoro the patient and either an x-ray tech or the SLP will feed the patient the barium.

More recently, mobile MBSS vans are becoming increasingly more available.   This means the patient may be taken out into the parking lot at a SNF, ALF, etc and straight into the van for the test.   Some mobile units also use a C-arm that goes into the patient room.

The Why

The why of the MBSS, as I mentioned above, is to evaluate the swallow in ways we can’t do bedside.  At bedside, we can’t SEE the pharyngeal phase of the swallow.  We are taking a variety of symptoms and inferring what we think may be happening in the pharynx. 

We look at the muscle movement and function.   We look at compensatory strategies, maneuvers or sensory strategies that may improve the swallow.   We look to confirm or to rule out the diagnosis of dysphagia, because how can we be certain when we are just staring at a throat?

The How

The how…..is variant.  Many people use a variety of techniques and consistencies for the MBSS.  This was part of the reason for the induction of the MBSImP, to standardize the MBSS.   Some people use every consistency they can find to feed the patient under fluoro, some use the Dr. Logemann set with 3 ml, 5 ml and 10ml liquids, etc.  

If you are an SLP and you complete your own MBSS, then I highly recommend looking into the Modified Barium Swallow Impairment Profile (MBSImP).  This is a standardized protocol for MBSS.

Some important parts of the MBSS, whichever technique you employ is:

1.  Analyze the patient’s swallow.  Look at the muscle dysfunction and piece together the patient’s history, bedside eval, etc, to examine the entire picture of this patient.

2.  There is no need to assess full meals and every consistency or texture the person may ever eat.  If you look at the muscle function, this gives you a good picture of your patient.

3.  Remember, an MBSS can be completed to answer questions and can be completed when the patient has a change in status whether that means an improvement or a decline.  

The Take-Away

No matter if you are a clinician completing the MBSS or the clinician treating the patient after the MBSS, it’s important to understand the MBSS.  Even if you never complete an MBSS, if you treat dysphagia, you should be able to interpret the MBSS.

You must be a competent dysphagia clinician to treat patients with dysphagia and you must understand the swallowing system in its entirety.

References:

The Step-by-Step Guide to Advocating For Access to Instrumentation for Our Patients

Attrill, S., White, S., Murray, J., Hammond, S., & Doeltgen, S. (2018). Impact of oropharyngeal dysphagia on healthcare cost and length of stay in hospital: a systematic review. BMC health services research18(1), 594.

Bonilha, H. S., Simpson, A. N., Ellis, C., Mauldin, P., Martin-Harris, B., & Simpson, K. (2014). The one-year attributable cost of post-stroke dysphagia. Dysphagia29(5), 545-552.

Bours, G. J., Speyer, R., Lemmens, J., Limburg, M., & De Wit, R. (2009). Bedside screening tests vs. videofluoroscopy or fibreoptic endoscopic evaluation of swallowing to detect dysphagia in patients with neurological disorders: systematic review. Journal of advanced nursing, 65(3), 477-493.

Ekberg, O., Hamdy, S., Woisard, V., Wuttge–Hannig, A., & Ortega, P. (2002). Social and psychological burden of dysphagia: its impact on diagnosis and treatment. Dysphagia, 17(2), 139-146.

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Logemann, J. A. (1997). Role of the modified barium swallow in management of patients with dysphagia. Otolaryngology–Head and Neck Surgery116(3), 335-338.

Logemann JA. Manual for the videofluorographic study of swallowing. 2nd ed. ProEd; Austin, TX: 1993.

Logemann JA. Evaluation and treatment of swallowing disorders. ProEd; Austin, TX: 1998.

Martin-Harris, B., Brodsky, M. B., Michel, Y., Castell, D. O., Schleicher, M., Sandidge, J., … & Blair, J. (2008). MBS measurement tool for swallow impairment—MBSImp: establishing a standard. Dysphagia23(4), 392-405.

Martin-Harris, B., Logemann, J. A., McMahon, S., Schleicher, M., & Sandidge, J. (2000). Clinical utility of the modified barium swallow. Dysphagia, 15(3), 136-141.

Palmer, J. B., Kuhlemeier, K. V., Tippett, D. C., & Lynch, C. (1993). A protocol for the videofluorographic swallowing study. Dysphagia8(3), 209-2

Patel, D. A., Krishnaswami, S., Steger, E., Conover, E., Vaezi, M. F., Ciucci, M. R., & Francis, D. O. (2017). Economic and survival burden of dysphagia among inpatients in the United States. Diseases of the Esophagus, 31(1), dox131.

Siebens AA, Linden PL: Dynamic imaging for swallowing reeducation. GastrointestRadio110:251-253, 1985.

Sura L, Madhavan A, Carnaby G, Crary MA. Dysphagia in the elderly: management and nutritional considerations. Clinical Interventions in Aging. 2012;7:287-298. doi:10.2147/CIA.S23404.

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