Chapters Transcript Video Anorectal Manometry – Start to Finish Webinar Series (2/3) HRiM: Review the test protocol, verification of proper placement of the probe, and the steps to acquire and edit a normal study. Welcome, everybody. I'm John L. Schmidt, the marketing director at the First Stocks Healthcare, and I'll be your host today. Diverse Tech Healthcare is excited to present the next webinar in our anal rectal Manama tree. Siri's exploring, high resolution intellectual Manama tree. Our speaker for today is Jason Baker, the coma tell with the director and director of clinical research at Atrium Health in Charlotte, North Carolina. He frequently presents a national and international annual scientific meetings and serves as a council member for the American Euro Gastroenterology and Motility Society. A few items before we begin this webinar is being recorded. It will also be uploaded to diverse Tech University. After the Siri's has ended, your microphones have been muted for the duration of the webinar. If you have any questions, please send them at any time be the questions box. Under go to Webinar panel, we will answer them during the questions and answer session. At the end, we'll do our best to answer all your questions and for those individuals that did not get their questions addressed, will respond to your question. Once the webinars over, I will now turn it over to Jason. Thank you very much. Good evening, everybody. Thank you for coming back to Webinar to, um this is gonna be an extension from webinar one, that kind of sequential in order, um, to learn more about high resolution and erectile Manama tree just for saving on terms, I'll probably say hi res a RM. Further it majority of the slides. But that refers the high resolution and erectile Manama tree things when we're gonna look at a standard protocol and really talk about talk about why this is the new standard protocol that you should really employ during indirectly Manama tree at your local institutions, some editing steps and then we're going to review a normal study and pick through a few abnormal studies. Thio give us a little flair for when you're editing, acquiring and editing the test. So so for some object objectives for this webinar, we're gonna basically review a standard high resolution Air M protocol and this is really becoming the gold standard of protocol for an erectile manama tree. Regardless of what type of platform you're using, we're gonna describe the steps of editing the high resolution air em and then also we're gonna you again a normal study almost an entirely then a few app. Pick through a few abnormal show you differences between the normal and the abnormal Hi res air. So this has really become the standard protocol. It's it's it's Ah, lot of the components have been in here for the majority of the time these for the last 20 years that I've been doing this. But it's really organized in a specific way now. And this is really from this is called the London Protocol. Similar? How esophageal has Chicago, um, classifications. PH testing has alien consensus in erectile has their own. It's really the London protocols. Been out for about two years. I think most people have been doing majority of this, but now it's in a sequential order, and I highly recommend that this is the order that you tend to do your anal rectal Manama trees again, regardless of platform. Um, and then even though if you have to talk, go through the different sections to collect all these acquire all these and we'll talk a little bit more about this time goes on, so the first thing it's highly recommended to get outside the body and erectile baseliner or a RBL that's called the erectile baseline. Just in case when you're putting the catheter in, you come up with some some restriction for for one reason or another, it could be to the stool. Retain stool could be thio, anatomical anomaly, all those type of things that you have the baseline that you can compare all the other pressures against outside the body. Um, instead of having a lot of pressure within an erectile baseline inside the body or in vivo. This is another reason why doing pretest homework just like similar we talked about and webinar one for an erectile and and the other webinars of the South of human on a tree that you really get to know what's going on with the pelvic floor of all those a priority things that may be causing different different issues. Why the catheter may not be, you know, place as a smoothly as, um, some other some other times when you place the catheter eso after you collect that interested baseline outside the body of the catheter, and it's basically just kind of laying it. You kind of wanna lay it in the same plane. The person is in. So maybe, just like right on the bed next to them, Um, for, you know, like, five seconds. So you need to record very short period of time. But then you place the catheter again, doing a very good rectal exam, visually and with your finger prior to introducing the catheter. Check for any bleeding or obstruction and also talk, making sure the patient understand what's gonna be going on. But after the catheters in you can secure by taping it on Ben, you wanna wait about a 3 to 5 minute adjustment period? You know, this is there's a lot of nerve endings down there. It's very sensitive. Patients need a little bit of time to get used to it and also allow they're arresting the tone. Become really quite essence. And not a lot of fluctuation of high pressure. Low pressure. Do you wanna encourage patients to get comfortable? Limit the patient's movement? Tell me, only gonna be in this position up to about 15 minutes, so you want to get them comfortable. Also, during this adjustment period, the next step after you have the the catheter fully inserted inside the body. Do you want to get in vivo in erectile Baseline. So it basically in a very quiet Essen area, a very quiet area. You want to try to get a indirect a baseline inside the body or in vivo? And that's, um, that's basically for a short period of time. It doesn't need to be a long period of time again. Five seconds. So just get a nice and directo baseline. Then after that, you're gonna reposition the probe into the anal canal, where you have the pressure band securely riding across that too far down on the screen. Not too far up in the screen, but right, kinda. In the middle of the band of pressure, some ambient pressure you're gonna see or blue pressure below the band of pressure A little bit above. And you'll see this band of pressure straight through. Look through some slides, um, of that position of the catheter. After that, you're gonna take a 62nd baseline measurement, and this is gonna be the resting pressure again. Encourage no movement, have a breed. Normally you don't want them hyperventilate or anything like that. Just breathe normally, like they normally do. After that on, you're gonna collect three. Squeeze measurements about five seconds long each. So squeeze, remember again is trying to hold it in. Don't let anything out. Take, take, take. Take five seconds. Then you're gonna let in between each one of these squeeze you're gonna let at least 30 seconds or until more importantly or until the pressure becomes back to the resting tone. So even if 30 seconds goes by and it's still higher pressure than the resting tone, you need to wait a little bit longer. You know, people with you just get occurred. People hemorrhoids, or is that had anal fissures, all kinds of little things. Sometimes it just takes a little bit more time to come back to quiet and arresting tone. Um, after those three squeezes, we're gonna we're gonna do another squeeze is gonna be a duration pressure. And this is where we're gonna do it for 30 seconds. So don't just sit there silent for 30 seconds. You wanna you wanna, you know, a little bit of a coach, like tell them five seconds. 10 seconds or 10 2030 whatever it may be. And then you and then you have them relax again. Have them bring normally during this. You don't want them holding their breath. But this time you're gonna wait at least 60 seconds or until the pressure comes back to resting tone. Uh, the next step, we're gonna ask him the cough. We want them to only have one abrupt cough. We don't want to cycle a cough. Like like that. We want one abrupt cough. Um, we're gonna do this during a squeeze. Measurement will rename it during analysis for cough. But we want one abrupt cough that we're gonna ask him to do one more abrupt cough again in between each cough, we want them to come back to resting tone or these 30 seconds, or until they come back to resting tone. The next step we're gonna do directorial inhibitory reflects, or the rare and sensation this is What we're gonna do is basically insert 30 ccs of air quickly in quickly out one second in one second out. Andi, they'll let you know if they felt that and you'll record that also, um, so you do 1 30. If it's not there, you can do another 30 after about least 30 seconds, or until the pressures come back to the resting tone. Some people may do a sequence like 10 2030 40 50 60 over the years, or pediatrics may be adjusted also. But this new London protocol, it's the 30 30 ml of air. You do once, and you could do one other one to evaluate the rare reflect. The next is we're going to push pushes the simulated defecation response. So they're really inside this protocol. They decide pushes basically like, uh, like, uh, bearing down like you're trying to have a bowel movement. That's basically what pushes means. So you wanna make sure they understand what that definition is Prior to starting, you're gonna have them do for 15 seconds. Let them know, don't worry about it. If anything's evacuated, that happens commonly. Eso doesn't give them the embarrassment factor again. Kind of counted off in 15 seconds. You know, get five more seconds, 10 more seconds or whatever it may be, then you wanna wait till it comes back to resting tone or at least 30 seconds in between each one of these three push maneuvers. Then the next step we're going to rectal sensation measurements. These are a little bit slower about two MLS a second again, Going back to Webinar one. We're gonna practice. You know, you can just kind of commonly practiced with your own syringe. But first sensation basically always define it over the last 20 years is that if you're watching your favorite TV program tonight, you can definitely wait till it's over. If you have urged dedicated that you got to go a commercial time. But Max tolerate means I gotta go right now in regards where we're at the TV program. It's kind of gender, non specific. So that's why we use the TV one for many, many years. The next part. We're gonna do a rectal compliance. We need at least three. It would be better encourage. You get four data points up to their maximum tolerated volume on what this means is basically, um, if their maximum tolerated volume is 200 we could do sequence of four sequence of 50 5100 and 5200. Or if the maximum volume is 125 50 75. 1 hunter, um, then the last part is blowing expulsion testing. You can't use the high res for balloon expulsion testing. It's highly likely you may damage the capsules cap probe. So basically, you have to use a disposable catheter to do that, so you'll take the high res catheter out places other one in inflated with 50 ccs of room temperature water. It makes it about the size of a silver dollar. And then, um then you basically either you put them on a ca mode and then you ask them thio try to expel their push their balloon out. But you want to current and not to rub their belly, Not the rock and roll or no finger manipulation during this sequence. So, again, the London classifications, all these measurements could be obtained within the bio view software, um, to employ the London classifications. So for patients set up, this is the first step going back to the webinar one. We're gonna show a little bit of this calibration of patients set up again on the screen. Right here is the first screen that comes up. Basically, you wanna only you're only required to put in all the ones with an asterisk all this other one that highly encourage you to put them in. Um, it helps you organize the study, find stuff a little bit easier as time goes on. But only things that are really required are the Asterix, Um, for and put the law, you to move forward the calibration window when we were talking about calibration and webinar one. These are the bars, and you see all the bars, all the channels down here go to 100 millimeters of mercury. After you see that, they're all staying pretty much stable. This is where you're gonna save those calibration values. These values will come back down near zero again. Then you just want to do a practice one again, pump it up, Um, 2 50 or you go all the way to a hunter and you can see making sure all the bars are basically standardized throughout. And it was the calibration was taken. Um, as when you start the protocol and you know you have basically the program, and you're gonna be the sequence will walk you right through. There's instructions will walk you through each step what you need to do. Um And what in order that you're gonna be able thio acquire the data throughout the entire record Manama tree. So the correct technique for acquisition this is really important because the better you acquire the test, the better the data is at the end point. So you always want to start the measurement area first, except during the compliance. But you always want to start the area. Measure first measurement first, so you want to click start before you ask them to do whatever they plan on doing it. During that part of the acquisition, The measure measure area needs to be a week. At least one second generally tends to be more if he started, and he let them know what to do than they do it. But at least one second and and then then after that, you won't allow 32nd period in between each maneuver. But more importantly, I think, don't get caught up in the 32nd mark. But more importantly, understand what that resting tone is. It could be a color mark, or you could just kind of get used to the values what each color represents, but it returns to the resting tone before then, before you ask them to do another portion of the test and then limit testing after you do the consent form and you the instruction part of the test. You wanna really limit the teaching? Either it's positive or negative feedback during the indirect Montri the literature has been shown and that your enhanced instruction or your positive or negative feedback does impact the results of the indirect in Manama tree. So do a good part of the beginning. Make sure they understand it through to teach back method. Then just let the study play out whatever they whatever they're doing during the test when you're asking, too, when you're requiring different portions of the section. So high resolution again and we're gonna talk about a little bit about the terminology of the high res Aaron So invaluable, Baseline Member, That's baseline inside the body. So the catheter is inserted all the way beyond the reference point that the last sensor and you can see right here in this window the balloon baseline and the anal canal baseline is very quiet. And remember, blue is really low pressures. As you see over here on nearly zero scale of red, it goes to about 1 50 so you can see it's very quiet and very quiet. Um um pressure. So you're collecting the enviable baseline But this is one thing. You again highly recommend collecting one outside the body. So just in case, for whatever reason, the catheters King ther does not laying Azaz flat assed. This one is right here that you got this baseline outside the body. So resting pressures as you see the depiction of the cartoon on the left compared to this band of pressure on the right. As you see, this catheter is perfectly placed. You got you got the external part of the body. Little blue little quiets an area. Then you got the band of pressure again. Low pressure here, abandoned blue, the quiet and pressure. So this is kind of like the band of pressure you're kind of seeing right through the middle of the screen. So you're going to see that this catheter is perfectly placed? Um, each one of these lines right here represents a portion onto the Catholic, As you see is red arrows are indicating this top one is the is the balloon. Uh, pressure compared to all these other, uh, uh, sensors, our correspondent, different portions of the anal canal and the resting tone. The resting pressure is primarily drive from the internal anal sphincter as we talked about the Webinar one. But there's probably some overlap, but primarily drive from the internal anal sphincter. But the squeeze pressure, same type thing. You see the catheter perfectly placed here, all the channels that represented by a different line in the orientation. But this time, when you ask him to squeeze, squeeze tight, tight, tight. Don't let anything out. Member for the first one is for about five seconds. This is mostly derived from striated muscle are expe so you have a lot of control over compared to the resting tone. But you, internally, those thinkers primarily derived from smooth muscle a little bit you don't have as much control on dis allows you to squeeze, squeeze, squeeze tight, tight, tight, um, to not allow anything to be evacuated from, they don't come out the squeeze duration compared to the sweet max squeeze pressure in the last one Squeeze duration is the one is for 30 seconds. So you're gonna ask them is this is primarily what we're looking at is the Channel one Channel two are basically the external sphincter muscle destroyed and muscle. When you ask them to do that, they're gonna have a transit increasing pressure. It's gonna be generally robust. And then it's gonna come back down almost instantaneous, and they gotta withhold 50% of that maximum pressure. So say they went from 0 5100. They got ahold with about 75 millimeters of mercury pressure for up to about 20 seconds. That's generally the rule of thumb of what we're looking for during this Max. This'll squeeze, duration, pressure, the cough again, We're going to start this in a squeeze measurement. We can rename it after inside the bio view of software, but we want one abrupt cough. You don't wanna cycles abrupt cough. And the reason is, there's really two fold. The first reason is this is this is an evaluation of gives us some evaluation of the integrity of the spinal reflex pathway. Secondly, is we want to know if you see this is really deep red pressure in here. Compared, this is is this less red up here? We want to know that this pressure right here is greater than this pressure right here. Because if you think about it, if this pressure is greater than this pressure as the this pressure is gonna overcome over force through here and then stool or mucus or contents could be evacuated because this pressure is greater than this pressure. So this is what we're kind of looking for inside, uh, the cough reflects. And also you want to kind of open up the, you know, pull the sheet up, pull the gown up and just take a quick peek and see if there's any mucus, stool, solid or liquid or urine. Or, you know, it could be blood. Sometimes if it's people may have some hemorrhoids or that type of thing, but you wanna definitely annotate that that there was some discharge. And what the discharges during the coffee for rare again rectally. No inhibitory reflects and sensation. You don't wanna let them know that you're starting. Your just gonna let them say we're gonna do the next portion of the test because you don't wanna basically, uh, provide like this enhanced instruction, but you want to do basically in and out really quick. And as you see, compared to the last couple, were Dr basically looking at the external anal sphincter or the bottom two channels. This one, we're really kind of looking at that more of the internal anal figures that you know 345 took of regions. You may see the sequences like in this one. You'll see that it goes all the way through the canal. That's good. It only has to occur within. You know, two channels for this occur at a relaxation, so inflate deflate, then this sentence is mostly smooth muscle. You'll see this muscle if they do have this, reflects it relaxed by itself and then come back to its resting tone. Um, is there any questions at all as we went through that first few slides? Sure. Is it okay to readjust the probe during acquisition? It's a good question. Um, it's gonna occur commonly, So even after you get it in, um, it's a good you make sure you see the visual where that band of pressure at is because someone may, when they're squeezing, they pull it in, or when they're doing different maneuvers, they may May, body will try to extract it out. So you want to make sure you have the press, the the catheter placed in the correct position to be able to acquire high quality data, but you may have to adjust it a few times during the test. I have one more. May I adjust pressure Pressure range during the acquisition? Tohave, uh, to visualize pressures more clearly. Yes, So you'll see that that that bar we saw on the right hand side, where is that zero? The 1 50? You can adjust that in real time, so someone that may, for example, have an extremely amount of strong pressure. You may wanna just that. So it's It's not completely red, pink, purple comps and, uh, and, conversely, someone who may have very low pressure. For whatever reason, it may be just quite blue or faints a green throughout the thing. You can adjust that where maybe the top part of the red is on Lee 50 millimeters of mercury pressure. But you want to be able to get yourself a very good eyesight on the band of pressure when you're performing these, but it's a You could do that real time during the study during acquiring the study. Okay, we'll just let us know if you have any other questions. We'll do another question thing before we go into the study, but so the indirect in Manama tree. The disinterested subtypes. We talked a little bit about this during webinar one there subtype Type one type two Type three type four. These are all obtained during the push maneuver. Again, type one is the dominant one. That's where the paradoxical contraction is set of them thinking they're relaxing. They're actually squeezing, but they also generate enough interruptible forced to have a bowel movement and type 23 and four are a little derivative, uh, kind of derived from type one Andi. But type one is the dominant one that you'll see quite often. Here's a similar image we talked. We show this grammatically from webinar one. As you see, this is what a normal would reflects would look like. And this was a of solid state catheter, um, years and years ago. But the images, no matter what type of Manama tree device you have, will be somewhat, very similar. Type one, I mean normal. Where you got enough interrupted pressure. The anal canal basically relaxes during that push maneuver. In contrast, type one you got enough interrupted pressure and then you have this paradox of contraction. Um, where it's basically tighten up. There's no relaxation at all. And, as you see type two Type three type for all derived a little bit differently from the type one. Take two. Same thing. Paradoxical contraction. Just not enough interactive pressure. Take three enough interactive pressure. Basically quiet and this. No equivocal, no change at all in anal sphincter. And then type four not enough for interactive pressure or in an equivocal nous and type in anal sphincter when they're trying. Thio, do the push maneuver again. Here's this basically states come, but we're just talking about like 50% of the time. If not Mauritz, mostly type one dis energy. So normal, similiar defecation again. What we're what we're what we're really looking at is that we want to increase in intra rectal pressure, so we wanna have enough force to push the stool contents. Um, some direct them into the anal canal and eventually outside the body that we want to decrease in the external anal sphincter pressure when they're actually doing so. Recognizing these pressure changes in the rectum and anal sphincter complex allows, you know, to determine the response during a simulated dedication during the push maneuver. So here's a little video of a normal. We can look through this. We're gonna it's gonna go from is gonna go from left to right here. As you see, right at this point, we're gonna ask them basically, and we're gonna watch it all the way to about this region right here. We're gonna ask them basically to push again. Member pushes where they're trying to simulate defecation. You get this pressure, then all of a sudden we're gonna they're gonna start to relax. You see it wide open completely blew enough for stool basically, uh, ableto evacuate the anal canal that eventually it gets back to, um where it's tighten up. We're still you're not allowing still to come back out of your body. In contrast, type one again. During that push maneuver, the patient's gonna paradoxically, contracting l sphincter again. They've got enough interruptible pressure. Then we're gonna ask them to basically watch the video from left to right. Remember, the last one is completely blew, and now it's like a pencil. Nothing's coming out. Nothing's coming out, but they're thinking they're trying to go the bathroom. They're thinking their own bathroom, but there's kind of it gets very frustrating. Very frustrating, very frustrating. but they think they're relaxing. But obviously you're seeing many metric Lee. They're not. So I used to use the how they teach people all time is I got taken by think of toothpaste but the metal film unscrew that you could squeeze, squeeze, squeeze. I just can't push any toothpaste out because that metal film it is tight. But if I pull the metal that little metal film off and I squeeze, it doesn't take much pressure to push the toothpaste out. So very similar. What's going on And type one verse. The normal simulated defecation responses take three again. There's just there's enough interest, indirect pressure. But again, nothing's really happening. It's just really equivocal to kind of stay in the same. There's really no relaxation at all kind occurring during this maneuver, Um, but again, again, very frustrating for the patient when they're trying to figure out why they're not being able to go to the bathroom normally and type 41 more Here we left the right the video. Not enough intellectual pressure. You see, it's basically just slightly bluer than here on BN. Nothing's really happening there, basically staying the same throughout the whole 15 seconds. So these air need things, and you can call go off this sink you on the right side when you're doing in real time The show. Especially if you have people in the room that people like to see these type of cartoons. It basically gives a visualization of what's happening, Um, with this pressure band and allows you to teach a little bit better. Slow sensation again about two MLS a second. Um, you're gonna ask them first sensation when they watching that TV show after the TV show urged at commercial Max tolerated. You know, I gotta go right now, and you're gonna You're gonna indicate on the test of the volume. Um, generally go up to about 300. Don't go. About 300 blues generally go through 400 but we've always stopped at 300. If you don't get 300 we just We label it as greater than 300. The rectal compliance this is the last portion of the Manama tree of the test is basically it's gonna cess areas of different inflation. So you're gonna you're gonna inflate the balloon, take whatever, remember, go back to your one slide. Whatever this maximum tolerated volume here is it's 1 60. You could just divide that by four. So you inflate the 40. We're gonna wait 30 seconds you're gonna collect of measurement. Then you're gonna inflated the 80. Wait, 30 seconds collected. Measurement. 1 20. Wait 30 seconds. Collect the measurement. 1 60 then wait 30 seconds collecting measurements. So you're gonna do this, and then you're gonna you're gonna do the exact same thing outside the body, um, with the same values. But you don't have to wait 2 30 seconds to do that Also. So any questions on that portion of the slide deck before we kind of go into editing steps and then looking at a few different studies? There is one are all three push attempts depicting similar pressure illustrations. Yeah. So, um, we're gonna talk a little bit about with editing part, but often, um, you'll see almost three different illustrations during each push maneuver. You know, I always say that's the first one is kind of like, You know, if you ever had this test done, I've had I participate in a research study many years ago, But I've had this done once. You know the first time You're like, um, what was I supposed to do? Because it's a weird thing. I'm in the left lateral position in the bed. You know, there's there's a little bit of a disconnect, so you don't really get you get you get a depiction. The second one, I think the patients kind of get like, Well, I think it's this type of issue. I'm gonna try this. I don't want evacuate anything, and then you get a little bit different response. But the third one, I always call, like the money one. They basically are, uh, you know, they get to the point there is going to give it a really all American try Type of issue. Eso often you'll see three. And during the London Protocol, they were very wise. Thio recognize this and it's been shown a little bit in the literature. Is that basically you're gonna You're gonna eventually select the best qualitative one, um, Thio for their final analysis. So, um, often they won't often. I'll be three. They may be slightly different, and sometimes they be they could be remarkably different. Okay, eso editing steps. So basically again, we're gonna take that we're gonna we're gonna zero the baseline when we when we get started, we're gonna just pressure ranges. Um, if necessary, Sometimes you don't usually from 0 to 1. 50. Often, that is, I would say probably 80% of time. That is, that is you won't have to Just that at all. Um, you're gonna maybe adjust some acquisition measurements if necessary. You're gonna verify all the events and annotations are accurate. Maybe add some things in there, like urine discharge or mucus discharge during cough or something of that nature. Um, you're gonna review the entire study and edit any marks if needed. Gonna save it. I often say save regularly. Safe, safe, safe, safe and then generate a report. So this is a picture of the probe. The high raising director. Manama Tree pro 2016. You know, directional pressure sensors, one balloon pressure sensor. It's about 16 little bit or 6.5 French and science of very small. Very smooth and easy to place. There's an editing, um, quick reference guide that's on the diverse tech university page that helps you kind of walk through the editing steps askew. Practice such as you're beginning your practicing how to do it. But there's a quick reference guide for review. Any questions? I'm gonna We're gonna bring up a few studies, but any questions at all? Okay, so we're gonna look at we're gonna look at a normal study first, As you see this kid's kind of orientate ourselves to the screen. So when it's first pulled up, um, so we're gonna look at this one, but the final report, we're gonna look at another one because of the identification issues. But as you see this, this right here, this first thing you'll bring up you basically see how long it took you to do the test. About 14.5 minutes. Zero average. Um, you've got to save button. You got all these toggle things, uh, that you can walk through and you just hover over them. They'll show you what they are like. Create measurement. This is an analysis tool you got. You can move through the test by going to measurement or going back to measurements. Previous measurements can go to the events to the previous events. Then you can also go to different pages, and these also ones you can show Mark your types and all these different things show events you could do all these different things as you walk through the study shows you the orientation of the catheter from the external reference all the way up to the balloon. And then over on this side right here, you'll see the pressure range again, 1 50 all the way down to about zero. And if you just pull these like this, you can see you can toggle and it changes the color on the screen all the way throughout the whole study. So we're just gonna keep it at 1 50. And you can also change your culture, the range inside the balloon also. All right, so the first thing that I gives me, but I was looking at about a two minute window The first thing I dio I just kind of take this black bar, and I just kind of pull it through and just get a good eye view of what's going on throughout the entire study. Very similar to this off of Jill. You just wanna qualitatively take a you know, just a view of to study, see if there's any, you know, odd things looking throughout. And and overall, this doesn't This is a very clean study throughout the entire state. Then I'll bring it all the way back. This is that an erectile, uh, baseline outside the body s O. We see. It's very quiet. Isn't as we collected that just in case we didn't get a good one? Here's our in vivo one. As you see, there is some pressure in here. We didn't get it. Really? That good one. And you can move these bars and you just need a little bit. You really want to try to get Aziz little pressure in here as as possible. Then the first thing we're gonna look at is arresting pressure here is you see, the resting pressure, um, is in this range of right here on day. Remember, this is gonna taken for 60 seconds, and you wanted them to stay very quiet. Very, you know, not moving very much china to hold their breath rate normally throughout. Now, when you get to these squeezes here inside the classification, uh, you wanna pick the best one of the three and you see, there's what you kind of look for its like, where has the most read. You see, Here's here's more red than these these ones. And if you put the cursor in their way could start to delete thes by just hitting the delete on your computer. If you want to put it back in, hit here and we're gonna put a squeeze pressure and then hit. Okay, we're gonna put this back in the cursor right there again. Hurt my sorry, Security. What? There you go. And then we're gonna put squeeze, and you can choose all the pressures by clicking on here. And then we'll create a measurement if you want to put it back in or say you didn't put it in the first time, you missed it or whatever that may be. And then then you can adjust as needed so you could make many different adjustments throughout the entire editing of the sequence. But during the squeeze of three squeezes you want to collect, you're only looking at the best one of the three. The next step here is the long duration squeeze. As you see, the photo right here, you see, is basically concentrating on the bottom two channels. The external anal sphincter, Channel one and two again, you're gonna basically have a transit increasing pressure, and then they're gonna need to hold 50% of that for at least 30 seconds. Then we're gonna go through the sequence of the rare direct hit Batory reflects again. Inflate, deflate. As you see, your eyeballs will see orange. Then you'll see yellow, then orange, and again to orientate yourself over here on the toggle screen. As you see, orange is a greater pressure than a yellow. So you see the relaxation that's occurring in between here and then 2030. If you do a sequence of 10 2030 40 50 60 or in the new London declassification, that is only looking at the 30 cc c mark. And then you see the pressure. It went into the balloon by this increasing pressure and higher and scale up into the red range. I hope so. Then, right here, as you see where way asked them to cough abruptly only one time right here. And if you click on the annotation, this comes up and then you can choose different things. There's a cough and then you hit, okay, and now this represents a cough. So you have to do this during the editing part. A cough, The next step here. Now we're gonna look at the simulated defecation, and this is the push maneuver, as you see, really read up here. So pressure is getting greater. Eso they have enough interested pressure. Look at the three here. This one looks much different than these two, right? This and then these two looks slightly different. So there's no no blue in here. It also barely any relaxation. And then these two, you see much more relaxation down into internal anal sphincter. So again it within the classification, you're only going to choose the best one qualitatively viewing at the best one for the final interpretation. Then the next thing we're doing that slow inflation. As you see up here, it says 51 20 and then 1 70. So, basically, we're slowly inflate about two MLS a second. They're gonna let us know when they first fielded them. And then they urged, And then when they maximum tolerated, um uh, then right after the maximum tolerated, even before you hit record on the screen of there's a little volume over here, it says, What volume? The blue blue in his injured just ah, go up to whatever that volume is, then you can deflate it right away. Then put your measurement, um, in measurement in. So the person doesn't have, like, this big balloon. While you're kind of messing around with the computer, I'm a big believer when you do the balloon expulsion test, Um, that right here you always annotate on the air and report again just by right clicking. And you can do hit a measurement of this little our line comes up, you can hit this little line and then over here, all events in directo. Then you can go down here and hit comment, and you can type, you know, whatever you want into, and it will show up on the screen. So then we're gonna move to a different one to show you the balloon compliance than what a report will look like. Um, um movie generate the final report. So this person has a name, but it's really did identify. It's Tom Hanks. Um, instead of Hank's is Tom Hanks. Hanks is are basically dummy study here, But again, we're gonna we're gonna move to the very end two minute window. So right here, as you see on what we did is that the person had 1/20 or Max and so we inflated to 30 waited 30 seconds, collected a measurement that we did 60 collected a measurement 30 seconds later that 90 collected another measurement. 30 seconds later, we collected three on this on this particular one. So after you went through this entire test and you major adjustments, you move the boxes a little bit. Here, there, remember, always start the measurement box one second before you ask them. Thio, acquire any of the data you made all your adjustments, you that type of thing, then we could go to the report. So if you go here to report, create report, this window will come up. And when you're setting up your software and different things, you can you can edit your template, but there's a standard one. Or keep the standard one and I headed Opener. That's why it's overriding it. But generally you won't see that. Then you'll get the standard report. It looks something like that. All the information that you put in before will populate here, so help you save some time. If you already had all this stuff in, you could put their patient history a little bit of homework type of thing that you did. So a little bit of story about the person, Any person medication, that your institution, You guys come up with a plan at your local place. What is, uh, worthwhile annotating The doctor could put in three impressions of what? What it may be, Um What? It may be what the director Manama Tree may have said. So it's all kind of here for you and then a final signature. You'll get a bunch of profile pressure profiles. You'll get the resting tone again. At each centimeter depth you'll get. You'll get senses of posterior left and anterior and right of the catheter. You're gonna get several different measurements, the mean one on each one of these steps all the way down. Then the average throughout. So you get each side quadrant lee than the average of each one of the centimeter depths and each section of the catheter. Then the squeeze print the same thing when you ask them to squeeze, um s in the squeeze, you know, hold tight, tight, tight saying type thing This is the maximum relative. The resting again. You're gonna get a portion of the poster right, left, and, anterior, they're gonna get an average of each summary of that. This is the cough again. This is more these air, some pressures that are occurring during the cough. Uh, max Relatives arresting. But again, it's It's so much. It's more about the pressure in external speakers that greater than the pressure into the incorrect pressure. Um, but these air some values for for you thio review Also then the summary of the some nations of the coffin non cough data, thes air, just some or numbers. But generally I would I would concentrate on these first three bar boxes of numbers. And this 1 may just be not as as of relevant, definitely with the one and classifications. The next section is simulated defecation response. It will give you basically what's happening in in, uh, Channel One and Channel two. Um, it's basically Thio again, left anterior and right in the poster, and it gives you an average. You may see negative numbers and that shows that you're there's a lot of relaxation. The differential. It shows a lot of relaxation. Or it can be completely positive that usually showing mawr off a paradoxical, uh, reaction to then pushing. They're trying to simulate defecation, so there's thes values will be very helpful. Um, then here's the percent of relaxation. Again, we want at least about 20% of anal relaxation. Thio. That's easy. Todo demarcation point to have enough and a relaxation Thio evacuate stool. So this person, as you see on average of all the four um, portions of the catheter, was well above 20%. The next section down here is squeeze duration. Ideally, you wanna have them squeeze greater than 20 seconds. So they were only able to hold 50% of their transit increasing pressure for about 1.8 seconds. Not very good than the sphincter length of their sphincter length. And there's a little bit of a normal range, um, for normal controls. So then you can you can you can look at these things. Also, these air just profiles looking at X Y and graph of each centimeter depth. These may be useful for you. They may not be useful for you. The fluctuations of changing the and the pressures among the right left, anterior and posterior. Um, there's one for squeeze also. Then there's the vector grass. It shows you basically, what portion of the canals generating the dominant force are the equally or the asymmetric or there's no cemetery at all, So these may be useful, especially of colorectal. Surgeon may order an erectile Manama tree with with your lab. Same thing here is a squeeze profile that's a Y, a graph of the all four quadrants and the changes in pressure and get it. And then the cough profile this one probably doesn't make. It's more of the Remember looking at the intellectual pressure verse. They you know canal pressure is more of the the what? You should be keen on more than these X Y graphs. Then there's another vector, one for squeeze. Where's where's the squeeze? Generating the Where is generating the tightness that you see it? Four. It's very, very tight. Compare that to and one. It was a little bit more Peyton. These are all things that could just add to your report, but I would mostly in the report. This is a cough one again, how, how much, how tight it gets around, how compared to how Peyton it is. But I would keep mostly on, um, mostly on the the numbers itself, the resting tone. Um, you want to use the absolute maximum value of resting tone of of during that 30 seconds. You want to use the maximum, um, squeezed pressure during the squeeze, the percent of anal relaxation, and determined this inertia, all these type of things that concentrate on the numbers more than on these things Grass. But these grass could be useful for dependent. Who's kind of ordering the tests than the than the rare and cessation? You see, the percent drop again. Generally, what we're looking for is greater than 15%. H d d. There was a huge amount of percent drop, so this was a normal response. So this is a report. You can kind of customize it. Um A So what you are needed throughout when you're starting to build your reports, what is needed for your ordering providers? What may be useful but may not be useful. I want to show one couple other things, and it could take some questions. Get out of this and all right. And I want to show right here. I think this is an important thing. So looks like a study that was acquired All the demarcations up here. Looks like we got everything. We got everything. Check, check, check. Check. Basically, but when you open it up the two minute window, you know, then he started tall. Go through here, You know? What do you think is going on here? This is is there's something that's not quite right. Correct. So remember what we're looking for is a little bit of basically quiet and pressure. Ah, band of pressure. A little bit of quiet and pressure, like so you got the solid band going across the screen are solid. Band is basically highlighted all on the bottom four channel. So you could this Katherine right here just wasn't place. Um, accurately. Thio really produce a high quality test. So this is this would be something like you. Keep your eye on the understanding the catheters placed correctly or incorrectly. So this is a This would be a very good if you could kind of stamp this in your neural library type of thing. This is what you would be kind of looking at when it's something. May not be placed as accurate. And one morning we could take questions. I just wanted to show you in comparison to the normal one member how we saw a lot of blue down here during their simulated defecation response. But that's toggle over to their simulated defecation response. And let's just look at quickly right here. The placement of this one. You know, it's you got some reference down here. That's OK. You got it up here today. His name may have a longer anal canal length, but good placement. Then let's go over here to when they're pushing. Whoa! Lot of read a lot of red in here and you could pull this down to see they're the pressure inside the bullet. So you see a lot of pressure here. There's, like, no relaxation at all that's occurring in this in this sequence at all, and you can hear place and you could see I'm sorry. You see it going from left to right here and then all of a sudden Whoa, Looks like that pencil again. There's like nothing coming out here still was coming down here. It is not getting beyond this point. Eso This is something this would be like true type one. Just energy even got worse from the first trial The second trial of third trial. Um, the response even got a little worse. Mhm So in summary, basically understanding what is being measured in each section of study will enhance your knowledge of the high res a RM terminology, but most importantly, improve your technical acumen skills of like acquiring ah, high quality test for the interpreting provider. Um, performing a consistent editing tool provides opportunities for rigorous generating rigorous measurement. So try Thio, use the same editing process throughout. So it z very consistent between all the teammates. But also it provides a very rigorous protocol when you're acquiring, um editing, analyzing, generating report. I appreciate everybody's time tonight. Will you take us many questions as as you have And look forward. The webinar three. Jason is there. A reference range available for normal ranges is a different from men, women, old young childbirth, etcetera. Great question. Great question. I think it's it's a multitude of issues. There is data on normal ranges, but I wanna say this within Asterix. Normal ranges may change by the catheter you're using. Normal ranges may change by the software you're using. Normal ranges do change between males and females. Normal change by the time it was done way back when different type of catheter designs eso there are some normal that you can kind of compare to out there. But I would take that with a little bit of a grain of salt. But the theory things out highly encourage we're gonna use normals. Make sure the normal that you're using our we're done with that same catheter, that same software and with the same type of, uh um of, ah protocol type of thing. So if you're looking at squeezes for five seconds, you know, make sure you're using if it's the mean it's the max, it's the differential between the resting and absolute. Make sure you're looking at the exact same measurements, or you're doing apples apples instead of apples or oranges. A great question. Looks like there's one last one. Should I perform a B E T during all intellectual Manami Manama tree procedures, even with patients with a diagnosis of fecal incontinence? Yeah, great question. I'm glad someone, um asked that question because it's let's start with the London We talked about the London Protocol London Protocol. Um um, it's not an option. It's It's part of the London Protocol. So the blue expulsion part test is part of the annual rectal Anoma tree. In the past, it used to be an ad jumped onto it, but now it XKE to use in the London Protocol to evaluate the push maneuver or the simulated defecation response. So in. So yes, you should do blue expulsion on every indirect Manama tree, regardless of fecal incontinence. Because sometimes there's a large person, a large for some of the pie that people that are feeble content could be also just overflow constipation. And you could see over time that some people, even PICO Kanis, can evacuate the balloon within the 60 seconds or 1 20 120 seconds whatever your lab decides to do. But everybody should get the balloon expulsion part and interrupted Manama regardless of, uh, diagnosis. The literature is pretty clear, getting clear at the days go on. But since the London really employees that part of the evaluation for to push maneuver, I highly recommend it. But remember the high risk catheter Erin should not be used for the balloon expulsion because of more likely damaging the catheter. You need to use another type of disposable device. Thio, perform the balloon expulsion test. Well, thank you, Jason. This concludes our webinar exploring high resolution in our common AAMA tree. Please join us next week on December 17 from 4 to 5 p.m. Central time for next webinar in the Siri's where we cover exploring conventional studies with disposable anal rectal manama tree probes. Thank you and good night. 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