Research Tuesday Post-Effects of Barium Concentration

I finally got back into the swing of things with Research Tuesday.

My article for the month is:  Stokely S., Molfenter SM, Steele CM.  Effects of Barium Concentration on Oropharyngeal Swallow Timing Measures.  Dysphagia (2014) 29: 78-82.

This study was completed as prior studies suggest that various aspects of the swallowing process, including timing measures may vary depending on the concentration of barium presented to the patient.

Subjects:  20 healthy adults

Given:  3 non cued swallows of 5 ml of barium (“thin” 40% concentration and “ultrathin” 22% concentration).

Results:

Longer stage transition durations (“the interval between the bolus head crossing the ramus of the mandible and the onset of hyoid elevation) with the 22% concentration.

Longer pharyngeal transit times (“the interval between the bolus head crossing the ramus of the mandible and closing of the UES”) were observed with the 40% concentration.

Longer durations of UES opening with 40% concentration.

Results:  “For all temporal measures of interest (stage duration, pharyngeal transit time and duration of UES opening) significantly shorter duration were seen with the 22% concentration than with the 40% concentration.”

“The 22% w/v “ultrathin: solution may act more like a true thin fluid such as water than a 40% w/v solution.  Although lower concentrations of barium appear less opaque on fluoroscopy, the study by Fink and Ross together with our own use of a 22% w/v concentration for several years, suggests that this concentration is adequate for visualization.”

The barium we use will and does effect timing events in the swallow.  If the barium solution is more concentrated, we can expect longer timing events in the swallow.  We need to be aware of the barium we use and mix it according to manufacturer’s directions or use a standardized recipe when assessing the events of the swallow.

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

I often feel I am very fortunate because I actually get to perform my own Modified Barium Swallow Studies (MBSS) or Rehab Swallow Study, Videofluoroscopic Swallow Study, Three Phase Esophagram…..whatever it may be called in your area.  I often wonder how clinicians work from some of the reports they receive.  I think back to the courses I’ve attended and the books I’ve read.  Dr. Logemann describes the MBSS as a procedure in which we find treatment strategies, compensations that help the patient swallow as safely as possible.  The main purpose of Dr. Martin Harris’ MBSImP is to discover the dysfunction causing the swallowing problem.  f

 We must always keep in mind that we don’t “treat” aspiration or penetration.  We treat the decreased hyolaryngeal excursion that causes the aspiration.

 There have been many times that I’m treating from a report another SLP had written.  I had no idea what direction to aim my therapy because the report merely stated aspiration.

 I’ve been reading questions from others, either from the Facebook groups or from the SIG 13 email forum.  There are always questions about modifieds, who’s appropriate, how to do it, what should be done.  Of course that triggers a blog post for me!!

 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) and 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 is probably unnecessary.  If I am looking at diet changes or most importantly, treatment planning and compensation 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 my x-ray techs and radiologists don’t like the C-arm is because it has increased fluoro exposure.

 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.

 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 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.

 The where is the fluoroscopy suite.  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.

 Varibar is the barium most SLPs use as it is already the consistencies we use, thin, nectar, thin honey, thick honey and pudding.  Or, if you are unable to get your facility to purchase Varibar, you thicken the drinks the best you can!

The why of the MBSS, as I mentioned above, is to evaluate the swallow in ways we can’t do bedside.  We look at the muscle movement and function.  If you are an SLP and you complete your own MBSS, then I highly recommend looking into the Modified Barium Swallow Impairment Profile (MBSImP).  It is a long course if you attend the live session.  You also have to complete the online section to become registered and use the tools.  You can also only do the online section and skip the live.  This course teaches you how to evaluate and score the muscle movements of the swallow per MBSImP protocol.  Another added bonus is, it decreases the amount of fluoro time for you and your patient.

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.  Dr. Crary and Carnaby suggest using their protocol for MBSS.  You can find the Carnaby Videofluoroscopic Data Sheet at Dysphagia Toolbox.

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.f

3.  Remember, although insurance will typically pay for an MBSS every 30 days, that does not mean that one is necessary every 30 days.

You can also watch a variety of MBSS videos on YouTube.