Posted on Leave a comment

Barium

So, you know all about MBSS, right? 

You’ve learned the MBSImP, you know all about consistencies, all about compensatory strategies.

What barium should you use?

We are often mixing the same barium used in other studies with food and liquid brought in from the kitchen.

At one point, there was a recipe available to make your own barium cookies.  You can also purchase these.

The thing is, when we use the same barium as used in the more in-depth esophageal tests they coat the structures.   That is what they were designed to do.   Sometimes that is all you can use because it’s all that’s available, but you have to remember there may be residue there, that wouldn’t normally be present.

The best option is to use Varibar, which was designed for the MBSS.  This is the same barium used in the MBSImP.

Not sure which compensatory strategies to use?  Read more by clicking on the picture!

untitled design

Maybe not sure about which consistencies you should trial?  Read more by clicking on the picture!

which consistencies do i trial

References:

https://imaging.bracco.com/us-en/products/fluoroscopy/varibar

Dantas, R. O., Dodds, W. J., Massey, B. T., & Kern, M. K. (1989). The effect of high-vs low-density barium preparations on the quantitative features of swallowing. American Journal of Roentgenology153(6), 1191-1195.

Logemann, J. A. (1993). Manual for the videofluorographic study of swallowing (Vol. 2). Austin, TX: Pro-ed.

Posted on 2 Comments

What Good is the MBSS if the Report is Not so Good?

I think we all get it. 

You work in a facility or for a company that has to send patients our for modifieds or instrumentals of any sort.

It’s Never Easy

You go through the works.   You have to evaluate the patient and try to scour through their paperwork to find out if they’ve had an instrumental.   You talk to the nurses and the DON, the DOR, the doctor and have to jump through a million hurdles just to get the patient out for the instrumental.

You sometimes wait for weeks for your patient to be scheduled and then finally get in for the study.

The Wait is Over…..Or Is It?

The patient comes back to your facility and all they can tell you is they had 2 bites of food and 1 drink and they were told to thicken their drinks.

You get the report (if you’re lucky) and find out that your patient aspirated on thin but not nectar thick (mildly thick) but they did penetrate so they are now on pureed food and honey thick liquids.

Your first thought….What the hell!!  Did they try compensatory strategies?  Did they try to change the bolus size?  Did they try anything?

The Report

You don’t know because it’s not in the report.

You may also not know how they responded to the aspiration, when it happened or why it happened.

The report is everything in the Modified Barium Swallow Study (MBSS).  The report is how the treating SLP knows what is happening and how they build the patient’s treatment plan.

What Happens in the Fluoro Room, Goes in the Report

You see, much like the evaluation you write or the plan of care you carefully create and document, the MBSS report has to be thorough and complete.  If it’s not documented, it didn’t happen.

You complete the best MBSS you know how so make it count with a great report.

Dr. Logemann reported on using compensatory strategies, sensory techniques and multiple trials of a bolus to determine swallowing deficits and how to safely keep the patient eating by mouth if possible.

We may use a chin tuck, head back or head turn to change the physiology of the swallow to improve the patient’s ability to swallow a bolus or even a variety of bolus types.

We may use sensory techniques such as pressure on the tongue, change in size of bolus or change in temperature of bolus to change the swallow.

Let’s Be Honest

The fact of the matter is, if we don’t give the patient a chance to swallow in a variety of ways during the instrumental, we may be sentencing them to thickened liquids or altered food consistencies.  We may be sentencing that patient to dissatisfaction, decreased quality of life, dehydration, malnutrition or even pneumonia.

Who Writes the Report

Palmer et al indicated the report includes a summary of what was done (position of the patient, bolus types presented, strategies trialed), a description of significant structural abnormalities, a summary of the observation of swallowing including each functional component, a diagnostic assessment, and recommendations.   Now, keep in mind, Palmer suggested the physician write the bulk of the report, I think we can agree the SLP writes the entire report.

Utilizing the MBSImP report generator can save time and ensure that you are providing a complete report.   Following a protocol and a report generator can ensure that nothing is forgotten, plus, if you can provide the radiologist with the protocol, it can save that surprise when they don’t understand what you are doing with a patient, which can lead to a discussion in front of the patient/family.

How are the reports in your area?  Good, great, need a little work?  How are the reports you write?

References:

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

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

Martin-Harris, B., Logemann, J. A., McMahon, S., Schleicher, M., & Sandidge, J. (2000). Clinical utility of the modified barium swallow. Dysphagia15(3), 136-141.

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.

 

 

 

 

Posted on 5 Comments

MBSImP

MBSImP

For those of you that don’t know what the heck the MBSImP is, it stands for the Modified Barium Swallow Impairment Profile.  What it is, an answer to everyone’s prayers to FINALLY have a standardized method for swallow studies.

Where Can I Find MBSImP

This protocol for MBSS is based on more than 10 years of work and research.    Northern Speech Services is the company that provides the MBSImP training which can be taken wholly or partially online.

The 17 Components

The MBSImP consists of 17 components from labial seal to esophageal clearance.  Each component is scored from 0 to either 3, 4 or 5, with the higher number indicating a worse impairment.  

The Training 

The nice part of the MBSImP is the training slides.  Each MBS frame has a corresponding animation making each component of the swallow easy to see for the training purposes.  The animations are used in the live course and the online module.  With the online module, you go through a training section, a practice section and then a test.  With the test, you have to have 80% reliability on your scoring.  Once you reach the 80% (you can take the test as many times as needed), you become a registered user and have access to a database.  This database allows you to input your patient information, which is de-identified to create a comprehensive report for each swallow study you complete.

 Part of the training is respiration and respiration in relation to swallowing.  One thing we learned is that most people will inhale and partially exhale before swallowing.  When the swallow is complete they will finish the exhalation.  It is important that we as therapists evaluate the respiratory pattern of the patient and take that into account.  One point that was emphasized was to teach an expiratory cough to clear and not cue the patient to inhale then cough.  Also to force “audible” vocal closure, or take a deep breath with an audible “huh”.

How In the Heck Do You Even Administer This Protocol? 

There is a complete outline including instruction to patient, what barium to present, when to present each consistency and how much to present.  This is done in a precise manner, however it was emphasized that you DO NOT HAVE TO FOLLOW THE PROTOCOL.  There will be times that you have to use your clinical judgement.  Now, with the database, Bonnie will have access to all of the inputed data, remember, it is de-identified.  To be a part of her collection of data, she needs to protocol to be standardized, but if it is not necessary or safe to standardize it for your patient, then you do it how you need to do it.

Scoring the MBSImP

With the MBSImP, you score each component with the given scale.  You are working to capture IMPAIRMENT.  This is not focusing on aspiration, penetration or testing every consistency known to man.  This is focusing on the function of the swallow and the dysfunction to create an appropriate therapy plan to rehabilitate the swallow.

This gives you a standardized score for the swallow study by entering all MBSS information and findings into a database, which creates your report.  This score allows you to demonstrate improvement and to focus on more than just penetration/aspiration, diet consistency, pooling, etc.  You focus more on the actual dysfunction.  The decreased tongue base retraction (TBR), the decreased pharyngeal stripping wave, they opening of the Pharyngeal Esophageal Segment (PES).  Dr. Martin-Harris uses PES rather than Upper Esophageal Sphincter (UES).

Thoughts on the MBSImP 

I think that this Profile came at the right time.  More than ever, we as SLP’s need to stand our ground and maintain our status as dysphagia experts.  We are the ones that study this mechanism.  We need to evaluate properly.  A modified should not be merely to determine aspiration or to see if the person if “safe” with thin liquids.  We need to determine dysfunction, rehabilitate the swallow system and re-evaluate to determine improvement of the function.  This will not only create a much nicer and less subjective study (really, what does mild, moderate and severe tell me?)

We don’t treat aspiration, penetration or premature spillage. We treat the dysfunction, the decreased hyoid protraction, the decreased laryngeal elevation.

 I think when we realize that dysphagia is muscle-based function of the body that works as a system, we can effectively diagnose and treat the dysphagia, the dysfunction instead of worrying so much about the actual aspiration or sticking our tongues out 10 times.  Then and only then can we call ourselves a dysphagia expert.

 All-in-all I’m still very excited about this protocol and the direction in which it takes our field.  I have been using this protocol since 2010 and I highly recommend it to all SLPs treating dysphagia, whether you actually are responsible for MBSS or not, you can still learn quite a lot about the swallow function and I believe it will be much easier to interpret the results if you have a therapist that uses the protocol.

References:

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.

Sandidge, J. (2009). The Modified Barium Swallow Impairment Profile (MBSImP): a new standard physiologic approach to swallowing assessment and targeted treatment. Perspectives on Swallowing and Swallowing Disorders (Dysphagia)18(4), 117-122.

Gullung, J. L., Hill, E. G., Castell, D. O., & Martin-Harris, B. (2012). Oropharyngeal and Esophageal Swallowing Impairments: their association and the predictive value of the modified barium swallow impairment profile and combined multichannel intraluminal impedance—esophageal manometry. Annals of Otology, Rhinology & Laryngology121(11), 738-745.

Martin-Harris, B., Humphries, K., & Garand, K. L. (2017). The Modified Barium Swallow Impairment Profile (MBSImP™©)–Innovation, Dissemination and Implementation. Perspectives of the ASHA Special Interest Groups2(13), 129-138.

Martin-Harris, B. (2017). MBSImP™ Web Based Learning Module. Northern Speech Services.

Tran, T. T. A., Martin Harris, B., & Pearson Jr, W. G. (2018). Improvements resulting from respiratory-swallow phase training visualized in patient-specific computational analysis of swallowing mechanics. Computer Methods in Biomechanics and Biomedical Engineering: Imaging & Visualization6(5), 532-538.