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The History of the Modified Barium Swallow Study

No matter what you call it…there is a history behind the Modified Barium Swallow Study (MBSS).

Gold Standard?

The Modified Barium Swallow Study has long been called THE gold standard in dysphagia evaluation, however it does have its limitations.   The MBSS definitely continues to be A gold standard in swallowing evaluation.

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Early Days

In the 1970’s, Dr. Jeri Logemann developed the MBSS or the Cookie Swallow Test.  She presented on this test at the ASHA convention in 1976.

During the Cookie Swallow Test, patients were given 2 cc of radiopaque liquid, 2 cc of paste, and 1/4 of a cookie coated with barium.  The liquid barium was given first, then paste, and last,  the cookie.   Patients were recorded with 2 swallows of each consistency.

Dr. Logemann then described liquid/food presentation as 3 swallows each of:

  • 1 ml thin liquid by spoon
  • 3 ml thin liquid by spoon
  • 5 ml liquid by syringe
  • 10 ml liquid by syringe
  • (can give larger amounts also)
  • Cup drinks
  • Saliva Swallow (no barium, just watch muscles move with swallow)
  • Pudding with barium (1/3 tsp or 1 ml of 2 parts pudding to 1 part barium)
  • Other food textures mixed with barium

Linden and Siebens,  developed a new approach to the VFSS which was based on patient specific deficits.  They used representative radiopaque foods similar to those the patient ordinarily ate.   The  study started with the food which would be safest for the patient to swallow, as determined by the SLP.  The study then progressed to increasingly difficult foods/liquids ending with those the patient was most likely to aspirate. Compensatory maneuvers (such as modifications of feeding or positioning) were tested  as a basis for developing recommendations for diet and treatment.

Standardized MBSS

Dr. Bonnie Martin Harris recently developed the Modified Barium Swallow Impairment Profile (MBSImP) which is the first standardized assessment of the MBSS.  (More on that to come!)

The Study

The MBSS consists of the patient, usually seated in a special seat, having an X-ray study, examining the oropharyngeal cavity.  The patient is given a variety of liquids and food, all mixed with barium as the barium can be viewed during the real-time video of the study.

The study is typically (should be) recorded for review of the test later.   The video can be slowed down for more accurate view of the swallowing structures.

Often, the MBSS is started and once the patient aspirates on the first consistency, the exam is discontinued.  This should not be the case as modifications can be made to:

  • amount presented
  • method of presentation
  • posture
  • position of head when swallowing
  • texture
  • temperature
  • taste

Although at one point, most SLP’s were completing the MBSS study to determine penetration/aspiration and what the best diet consistency is for the patient to safely consume, we now know better.

The MBSS is a test that allows us to view the oropharyngeal structure from the side (lateral) and from the front (A-P view) to determine the physiology of the swallow, meaning that we determine what muscles are moving and how.

Although we may test a wide variety of consistencies, thin liquid, nectar thick (mildly thick), honey thick (moderately thick) liquids, pureed, mixed consistencies, soft foods and regular foods, there is no way for us to possibly test every single consistency the person may consume.

But Why MBSS?

That is why it is important to look beyond penetration and aspiration and to look at the physiology of the swallow including what is functional and what is not.   This is what leads us to accurate diagnosis and treatment planning for patients.

More to come on the MBSS!

References:

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.

Linden PL, Siebens AA: Dysphagia: predicting laryngeal penetration. Arch Phys Med Rehab 64:281-284, 1983.

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

Linden P: Videofluoroscopy in the rehabilitation of swallowing dysfunction. Dysphagia 3:189-191, 1989.

Palmer, J. B., Kuhlemeier, K. V., Tippett, D. C., & Lynch, C. (1993). A protocol for the videofluorographic swallowing study. Dysphagia8(3), 209-214.

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. Dysphagia15(3), 136-141.

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Cervical Auscultation

 

What is Cervical Auscultation?

Using Cervical Auscultation (CA) involves the use of a stethoscope, placed on the throat to “listen” to the sounds of the swallow.

Clinicians often use CA to assess swallow sounds and airway sounds.  Judgements are made on the normality of the swallow or the degree of impairment of swallowing.

Cervical Auscultation and Swallowing

In theory, “there are specific sounds related to events of the swallow.”   Some clinicians indicate that a swoosh, a click or a clunk can indicate physiologic events such as premature spillage, aspiration, laryngeal vestibule closure, penetration, etc.

Many clinicians swear by cervical auscultation, even replacing imaging with auscultation.

There is also an argument that there is no evidence on what causes swallowing sounds or whether these sounds correspond to physiological swallowing events.

The evidence tells us that CA may not be all it’s cracked up to be.

What does the Evidence Tell Us? 

A systematic review of cervical auscultation by Legarde et al 2016, reviewed 90 articles.  Using inclusion and exclusion criteria 6 articles were included in the review as the other articles did not meet criteria to be included.   (Full article can be accessed at the link below.)

The review found that the reliability of Cervical Auscultation is insufficient to be used as a stand-alone tool in dysphagia in adults.  There is no evidence of reliability or validity in Cervical Auscultation in the pediatric population.   Cervical Auscultation should not be used as a stand-alone tool in the diagnosis of dysphagia.

When CA was synchronized with endoscopy (Leslie, et al, 2007), they found that there was a wide-spread degree of the timing of swallowing sounds and physiologic events.  No individual sounds was consistently associated with any physiologic event.  There was no link between:

  • Pre-Click and onset of apnea
  • Pre-Click and the start of epiglottic excursion
  • Click and the epiglottis returning to rest
  • Click and the end of swallow apnea

They also found that the absence of a swallowing sound was not a sign of pathologic swallowing but that a repeated abnormal pattern may indicate an impairment.

In conclusion there is no robust evidence to support CA in dysphagia and judgement between SLP interpretation of sounds or absence of sound was poor.

Do You have an Opinion?

What do you think?  Are you for or against CA?  Maybe you have no opinion either way.  Let me know in the comments!

References:   

Lagarde, M. L., Kamalski, D. M., & Van Den Engel-Hoek, L. E. N. I. E. (2016). The reliability and validity of cervical auscultation in the diagnosis of dysphagia: a systematic review. Clinical rehabilitation30(2), 199-207.

Dudik, J. M., Coyle, J. L., & Sejdić, E. (2015). Dysphagia screening: Contributions of cervical auscultation signals and modern signal-processing techniques. IEEE transactions on human-machine systems45(4), 465-477.Leslie, P., Drinnan, M. J., Zammit-Maempel, I., Coyle, J. L., Ford, G. A., & Wilson, J. A. (2007). Cervical auscultation synchronized with images from endoscopy swallow evaluations. Dysphagia22(4), 290-298.

Leslie, P., Drinnan, M. J., Zammit-Maempel, I., Coyle, J. L., Ford, G. A., & Wilson, J. A. (2007). Cervical auscultation synchronized with images from endoscopy swallow evaluations. Dysphagia22(4), 290-298.

Leslie, P., Drinnan, M. J., Finn, P., Ford, G. A., & Wilson, J. A. (2004). Reliability and validity of cervical auscultation: a controlled comparison using videofluoroscopy. Dysphagia19(4), 231-240.

Borr, C., Hielscher-Fastabend, M., & Lücking, A. (2007). Reliability and validity of cervical auscultation. Dysphagia22(3), 225-234.

Stroud, A. E., Lawrie, B. W., & Wiles, C. M. (2002). Inter and intra-rater reliability of cervical auscultation to detect aspiration in patients with dysphagia. Clinical rehabilitation16(6), 640-645.

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What Would You Do?

I would love to share a story with you. 

Now keep in mind, I’ve been an SLP for a lot of years and feel that I do a pretty good job.   Sometimes, I may even get a little over-confident in my skills and have to examine what I’m doing.

Let’s talk about a patient I’ve had.   All identifying information will be withheld. 

This person was referred after a family member was concerned with increased choking with food and drinks.   This patient has a history of dysphagia, which had resolved. 

I get the call to go in and go in prepared for an evaluation. I did everything I would normally do in an evaluation.

I did a cranial nerve exam which all the cranial nerves seem to be intact. I had the person eat and drink while I observed. I even palpated the larynx to see what I could feel. Everything seemed to be quite normal.

I have to do vitals for home health so I went ahead and got out my pulse oximeter to see if there is any change in the person’s sats. They were able to drink some water with no change in 02 saturation.

Everything seemed to check out pretty well however the family was still very concerned, so just to cover my bases and to make sure that I hadn’t missed something I requested a modified barium swallow study.

Now imagine my surprise when I get the report for that swallow study and find out that this person’s actually aspirating multiple consistencies.

The person has timing issues with laryngeal elevation and closure and with oral containment prior to the swallow.

I mean really how can that be?

There was no change in O2 sats for me. The larynx felt like it was moving pretty well. Cranial nerves seem to be intact and functioning.

Where did I go wrong?

I didn’t. I realized my limitation without visualization. I have read my research and know that O2 sats and palpation is not always accurate.

I did right by my patient and pushed for instrumental exams.

I had push-back at first. Do you really need an instrumental? Can’t you just treat? When I told the company I need the instrumentals or I’m referring patients to another company, they started approving my requests.

Do right by your patients.

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Go With the (Peak) Flow

 

A Clinical Swallow Evaluation is a series of screens that we use to determine if the patient requires more testing or not.

Let’s face it, whether we like it or not, insurance likes objective data, including numbers indicating a deficit or no deficit.   Peak Flow is a tool that gives us objective numbers to input into our reports.

What is Peak Flow?

A Peak Flow meter measures how fast air is expelled from the lungs in one fast blast.  A Peak Flow meter can be very beneficial to those with asthma.

Peak Flow also gives us information on the cough reflex and function of the cough, in turn, allowing us to determine patients that are at risk for penetration and/or aspiration.

Why do we care about coughing?

Coughing is a mechanism of airway clearance that adds to normal
ciliary function comprised of three events

  • Inspiratory effort
  • Followed by rapid vocal fold adduction
  • Contraction of the expiratory muscles

Respiratory Muscle Strength Training (RMST)

You can also use Peak Flow to determine baseline for RMST and to measure outcomes throughout your therapy using RMST.

So what has research told us about measuring Peak Flow?

We measure using PEF or Peak Expiratory Flow or PEFR Peak Expiratory Flow Rate.

  • Smith-Hammond, et al 2009-Peak flow identified 82% of aspirators
    (stroke patients) at PEF <2.9 L
  • Pitts, et al  2010-Peak flow identified 86% of aspirators (Parkinson’s) at
    PEF <5.2 L
  • Suarez, et al 2002 identified 74% aspirators (ALS) at
    <4.0 L
  • Plowman, et al 2016 identified voluntary cough airflow in patients with ALS at risk for penetration/aspiration

Peak Flow meters can be purchased to use.

PF 1        PF 2

A less expensive Peak Flow model will have a plastic piece on the side that moves as the person exhales or coughs into the device.   You can determine the PEF or PEFR by having the person exhale or cough into the device 3 times and figuring the average rate.

PF 3

You can also purchase a digital device which will give you a more accurate reading, but will cost you a bit more.

These devices can be purchased on Amazon or a medical supply store.   You can often purchase disposable mouth pieces so that you can use the device with multiple patients after cleaning.

References:

Gregory, S. A. (2007). Evaluation and management of respiratory muscle dysfunction in ALS. NeuroRehabilitation22(6), 435-443.

Hammond, C. A. S., Goldstein, L. B., Horner, R. D., Ying, J., Gray, L., Gonzalez-Rothi, L., & Bolser, D. C. (2009). Predicting aspiration in patients with ischemic stroke: comparison of clinical signs and aerodynamic measures of voluntary cough. Chest135(3), 769-777.

Pitts, T., Troche, M., Mann, G., Rosenbek, J., Okun, M. S., & Sapienza, C. (2010). Using voluntary cough to detect penetration and aspiration during oropharyngeal swallowing in patients with Parkinson disease. Chest138(6), 1426-1431.

Plowman, E. K., Watts, S. A., Robison, R., Tabor, L., Dion, C., Gaziano, J., … & Gooch, C. (2016). Voluntary cough airflow differentiates safe versus unsafe swallowing in amyotrophic lateral sclerosis. Dysphagia31(3), 383-390.

Suárez, A. A., Pessolano, F. A., Monteiro, S. G., Ferreyra, G., Capria, M. E., Mesa, L., … & De Vito, E. L. (2002). Peak flow and peak cough flow in the evaluation of expiratory muscle weakness and bulbar impairment in patients with neuromuscular disease. American journal of physical medicine & rehabilitation81(7), 506-511.

 

 

 

 

 

 

 

 

 

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The Yale Swallow Protocol

 

I think that we have all looked for that simple and easy screen that we can use for patients to identify a possible dysphagia.

We want a screen that’s not only easy for us to administer as an SLP, but that we can teach other professionals to utilize to assist in their referrals.

Let’s face it.  If you work in acute care, AND your building is stroke certified, you are probably already getting a referral to assess every single stroke patient that walks in the door.

So maybe we can use a screen, like the Yale Swallow Protocol to assist in screening patients.

The Yale Swallow Protocol was once known as the 3 Ounce Swallow.   This came from research looking at how accurate a screening could be by having a patient drink 3 ounces of water.  There is also a study looking at the efficacy of how much liquid is enough to elicit a cough response and 3 ounces seemed to be that magic number.

When administering the Yale Swallow Protocol, part of the protocol is an oral mech exam.  You really want to take a look at the oral structures and how they are functioning.

You also assess cognition.  How well does the person follow 1 step directions and accuracy of following yes/no questions.   Leder, Suiter and Warner  found that when patients are not oriented x3, they may be 31% more likely to aspirate.

There was also a correlation between aspiration and the ability to follow single step directions.   When unable to follow single step directions, patients likelihood of aspiration of liquids increased to 57%, pureed 48% and deemed unsafe for any oral consistency to 69%.

The Yale Swallow Protocol is easy to administer:

  1.  Give your patient a cup with 3 ounces of water.   (I always given them water that is room temperature.)
  2. Have your patient drink all the water without stopping until it is gone.
  3. They pass if:  they are able to drink all the water without stopping with no coughing or signs of swallowing difficulty.
  4. They fail if:  they are unable to drink all the water without stopping or they cough while drinking the water or immediately after.

Now, there are populations with whom I DO NOT use this screen.  I would not do this with someone who is:

  1.  not medically stable
  2. has severe respiratory issues
  3. severe dysphagia
  4. aspiration on previous bolus administration
  5. unable to manage secretions.

Want more information?

You can earn continuing education with Debra Suiter on Medbridge

Purchase the book on Amazon

Listen to the Swallow Your Pride podcast episode with Debra Suiter

References:

DePippo, K. L., Holas, M. A., & Reding, M. J. (1992). Validation of the 3-oz water swallow test for aspiration following stroke. Archives of neurology49(12), 1259-1261.

Suiter, D. M., & Leder, S. B. (2008). Clinical utility of the 3-ounce water swallow test. Dysphagia23(3), 244-250.

Garon, B. R., Engle, M., & Ormiston, C. (1995). Reliability of the 3-oz water swallow test utilizing cough reflex as sole indicator of aspiration. Journal of Neurologic Rehabilitation9(3), 139-143.

Suiter, D. M., Leder, S. B., & Karas, D. E. (2009). The 3-ounce (90-cc) water swallow challenge: a screening test for children with suspected oropharyngeal dysphagia. Otolaryngology—Head and Neck Surgery140(2), 187-190.

Suiter, D. M., Sloggy, J., & Leder, S. B. (2014). Validation of the Yale Swallow Protocol: a prospective double-blinded videofluoroscopic study. Dysphagia29(2), 199-203.

Suiter, D. M., & Leder, S. B. (2009). 3 Ounces Is All You Need. Perspectives on Swallowing and Swallowing Disorders (Dysphagia)18(4), 111-116.

Warner, H. L., Suiter, D. M., Nystrom, K. V., Poskus, K., & Leder, S. B. (2014). Comparing accuracy of the Yale swallow protocol when administered by registered nurses and speech‐language pathologists. Journal of clinical nursing23(13-14), 1908-1915.

Leder, S. B., & Suiter, D. M. (2014). The Yale Swallow Protocol: An evidence-based approach to decision making. Springer.

Leder, S. B., Suiter, D. M., & Warner, H. L. (2009). Answering orientation questions and following single-step verbal commands: effect on aspiration status. Dysphagia24(3), 290.

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“Establishing a Multidisciplinary Head and Neck Clinical Pathway: An Implementation Evaluation and Audit of Dysphagia-Related Services and Outcomes”

 

If you are considering joining or starting a head and neck cancer program, this is the read for you!

I was searching through articles this morning and found this very article stating the importance of a team approach and a systematic approach to head and neck cancer!

“Head and neck cancer guidelines recommend multidisciplinary team monitoring and early intervention.”

Prophylactic treatment for head and neck cancer has been found to increase maintenance of tongue muscle mass, preserve some taste and have an overall improved swallow.   The SLP should be right in there, from the beginning to determine baseline swallowing function and to provide education for what may happen to the swallow.

“We need patient care using a systematic approach for head and neck cancer.”

Read the research.  Keep up with the new approaches and utilize them in  your therapy.  Dysphagia assessment and treatment approaches are ever-evolving and you have to stay current to provide your patients with the best care possible.

With the multidisciplinary Approach:

  • Improved outcomes
  • Better survival rates
  • Maximize results through use of a coordinated pathway
  • Increase efficiency in care delivery
  • Reduce cost
  • Shorten the length of the hospital stay
  • Improve overall patient outcomes

Who should/may be on the multidisciplinary team:

  • Head and Neck Surgeon
  • Medical Oncologist
  • Radiation Oncologist
  • Nursing
  • Speech Language Pathologist
  • Dietician
  • Social Worker
  • Administrative Professionals (Systems Analyst, Clinical Research Coordinator)

“A significant impact of Head and Neck Cancer is typically the impact on swallowing and inadequate nutritional intake.”

The SLP plays a vital role in the assessment and treatment of swallowing.

“Prophylactic and ongoing Speech Language Pathology services can be vital by impacting swallow function, nutritional status and overall quality of life.”

We’re not just one and done.  Even though the patient may not initially have difficulty with swallowing early in their treatment doesn’t mean it will never happen.   You need to check up on the patients throughout their course of treatment and even after their treatment to continue to assess the impact on swallowing.

Collecting Data:

Patients undergo a pre-treatment MBSS (Modified Barium Swallow Study) and/or FEES (Flexible Endoscopic Evaluation of Swallowing).  Also completed with patients:

Prophylactic Exercises Included:

  • Lingual strengthening
  • Masako Maneuver
  • Effortful or Supraglottic Swallow
  • Mendelsohn Maneuver
  • Shaker
  • Therabite (incisal opening less than 40mm)
  • EMST (increase airway clearance/protection)

*Exercises completed 2x/day, 6 days/week

References:

Dance Head and Neck Clinical Pathway (D-HNCP)

Messing, B. P., Ward, E. C., Lazarus, C., Ryniak, K., Kim, M., Silinonte, J., … & Sobel, R. (2019). Establishing a multidisciplinary head and neck clinical pathway: An implementation evaluation and audit of dysphagia-related services and outcomes. Dysphagia34(1), 89-104.