Chapters Transcript Video Anorectal Manometry – Start to Finish Webinar Series (3/3) Disposable ARM Probes: Review the test protocol, verification of proper placement of the probe, and the steps to acquire and edit a normal study. Hello and welcome everyone. I'm John L. Schmidt, the marketing director here, a diverse tech healthcare, and I'll be your host today. Thank you for joining us. Today is the last webinar in our anal rectal Manama tree. Siri's exploring conventional studies with disposable a RM probes. I'd like to introduce our speaker for this. Siri's Jason Baker Jason is the co motility director and director of clinical research at Atrium Health in Charlotte, North Carolina. He's a frequent presenter and national international annual scientific meetings, and very recently he was elected as a council member for the American Euro Gastroenterology and Motility Society. A few quick items before we begin, the webinar is being recorded and will be uploaded to diverse Attack. University at the Siri's has ended. Your microphones have been muted for the duration of the webinar, and if you have any questions, please send them at any time you have 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 questioning addressed, we will respond to your question. Once 11 years over, I will now turn it over to Jason. Good afternoon, everybody. Welcome back to part three of our indirect of Manama tree. Siri's um, we appreciate everybody participating. We think it's been a very exciting webinar and and educational at the same time. So part three or what I've been are serious conventional way form. An erectile Manama tree with disposable probes will probably use the terminology disposable air em throughout this thing. This this webinar But this is what we're referring to. We're gonna look at a standard protocol editing steps. Then we're going to review a normal study. So So for some simple objectives for this webinar, we're going to review the standard conventional air and protocol. We're going to describe the steps for editing this type of anorexia. Manama tree. Then we're gonna look at a normal study then and we'll show you what talked through what an abnormal, simulated defecation responsive push maneuver would look like in disposable air and test. So here is an image of Remember when we looked at high resolution in a recommend um, a tree catheters. You see, they were very a lot of sensors. Very closely spaced along three catheter. Thats one is slightly different. This one over here on the upper left hand corner, the four channel radio. This is mostly used in pediatric world. You don't do any pull through. You see the four little balloons here that air charged balloons. Eso it's mostly done in the pediatric ward. So we're not gonna spend too much on here since the weapon has been mainly focused towards adults. But this catheter over here on the right hand side, is more of the an illustration. What? Um, a disposable interrupted Manama tree. Catherine would look like you got these four balloons again on the posterior anterior, right and left. The balloon comes attached already, so you don't have to attach it in comparison to the, uh, high resident indirect economic catheter. It's not like tax and and it connects to basically this connection cable as you see the color here almost like similar when you're doing your Christmas tree, got red, green, blue and yellow, and they color code connecting to this cable, which allows the charge of the balloons to occur. Um, and go back one slide here. The other good thing about when you're doing disposable indirect in Manama Tree testing. You could also use the same catheter for blue and expulsion testing. In contrast to high resolution interactive Manama tree, you gotta use another commercial device for blue and expulsion testing. So the standard protocol for disposable indirect in Manama tree similar to the high res Um, with a couple little caveats difference. And we're gonna kind of walk through there and highlight which, which are the little caveat differences. So again, it's highly recommended that you obtain anal rectal baseline outside the body or air B. L again. That's just in case when you placed a catheter in. It's just not setting, um, in a fashion where you're not getting any artifact on the screen, you just still have that as your back up, just in case. But, um, so highly recommend taking this air B l outside the body. It could be for, you know, five seconds doesn't mean to be for a long period of time. As long as you click record on the screen itself, then you're gonna let an adjustment period happened. You're going again. Talk about to talk to the patient, limiting their body movement. Get them into a position. They're going to be comfortable for about 15 minutes, especially people that had hip or knee surgeries or back issues. You want to get them comfortable, Pillow comfortable, all that type of stuff during this adjustment period. Then, at that point, you got to have the catheter in about 10 centimeters. You're gonna pull it back to the six centimeter demarcation point and you're gonna collect this in. Vivo are inside the body and erectile baseline again for about 10 15 seconds. Doesn't have be a long period of time. After that point, you're going to start the resting pressure Pull through. That's where on the catheter itself, it has centimeter markings throughout. So you know exactly where it's at. But you're gonna do resting pressure at five centimeters, four centimeters, 3 to 1. As you're pulling this back, you want the peach patient to breathe normally, you don't want them to be, you know, hyperventilating or someone of that nature. And then as you pull it, you're gonna let the you're gonna get some artifact in between each one of these pressure just because you're sliding through a very sensitive, very a lot of nerve innovation. But after it gets to a nice, quiet or quieter tone, you're gonna take a measurement duration at 10 seconds for each one of these. 54321 The other thing you want to keep your eye on You want to keep your eye on where in here does it exert the greatest amount of pressure? Most of the time it falls, you know, 3 to 1 in that category. But keep your eye on. And just so you remember which which one of these pressure centimeter deaths exert the greatest amount of pressure Because eventually you're going to tape it at that centimeter mark for the remainder of the tests. After you go 54321 and get the resting pressure, You're gonna move it back in 25 centimeters. Let everything come back, Thio Normal resting tone without a lot of artifact movement. Remember, instruct them to breathe normally. Then at 54321 This time, we're gonna have them squeeze tight for about five seconds. Squeeze means you're not trying not to let anything out and five and you hold it for about five seconds. Then you're gonna move on to 4321 But in between these squeezes, you want to give it some time? Sometimes it could be up to 30 seconds for this. The pressure tone to become quiet and again. After that's done, you're gonna place it at the highest exerted pressure during the resting pressure. Pull through for the remainder of the test. Then after that, after everything is calm down and you get it, take into position we're gonna do to squeeze duration measurement. This one's gonna be for 30 seconds. You're gonna have them sustain that pressure for 30 seconds. Remember, counted off in five second increments. Don't stay. Silence. And this be a partner with the patient during this test, this part of the test so they almost like a coach after the after the 32nd squeeze duration is over. You're going to give it at least 60 seconds to move on before you move on to the cough measurement. Or more importantly, until the pressure be returns to the resting pressure again at the next point, we're gonna ask them to cough. You want them abruptly cough only once. We're going to start this in a squeeze measurement type of frame, but then weaken Relabel it during the analysis stage. So one abrupt cough. Then you're going again. Wait till it comes to resting pressure or at least 30 seconds to do another abrupt cough. And then at that point after each cough, you definitely wanna open up, pull up the gown or the sheikh just to see if there's any discharging were eventually annotate that on the screen. Whatever that may be, the next is we're gonna do the rectal Any inhibitory, reflex or rare and sensation. This is gonna be a 30 m. Els. So we're gonna insert 30 m Els and pull it back quickly like one second in one second out. And then you don't wanna You don't want to let them know it's coming because you want them to let you report to you that they felt that. But if you don't see this relaxation and we're gonna look at one of the normal study, then we get to do you do one more. So this is all referring back to that London protocol. So eventually you do up to a maximum of two. Some people do 10 2030 40 50 60. But the newer protocols are only doing 30 if you don't. If it's kind of equivocal or not really unsure, you could do one more the next step we're going to ask them to push. Push means simulate defecation like they're trying to have a bowel movement. So we're gonna have them push, push, push, push. And before you start this, you should, you know, kind of let them know, do not feel embarrassed if something comes out and make occurs commonly, so just have them push, push, push, push for about 15 seconds. And then after they do that, you're gonna have them rest until it comes back to the resting tone or 30 seconds. Whatever occurs first, we're gonna happen to do at three times. And then again, with coming back to resting tone in between each resting pressure in between each maneuver a t least 30 seconds. The next part, we're going to slowly inflate the balloon about to MLS a second. We're gonna ask him when they first have a first sensation and urge to defecate and maximum tolerated. First sensation kind of means, you know, if you're watching your favorite TV show again, you can wait till it's over and urge to defecate means, you know, you have to go a commercial time. Maximum tolerate means I gotta go right now. Regards where? We're at the TV pro. Okay. Remember the volume right here? Maximum tolerated. So the next part is the is rectal compliance. So basically, we're gonna take this maximum tolerated volume. We're gonna try to get least four, um, data points. Three would be the minimum We're trying to get to four. Whatever. This this will say, it's 100. We're going to divide that by four. So 25 50. 75. 100. And what we're gonna do is we're gonna inflate the balloon to 25 then wait 30 seconds. Collect the measurement. Inflated the 50 20. Wait 30 seconds collected. Measurement another 25 to 75. Wait 30 seconds of measurement, then in the last 25 mls of their wait 30 seconds. Collective measures. After you collect all those, you're gonna deflate the balloon until a pit, and then you're going to remove it at this point, keep it on like a blue pad or a towel right next to them, and then you're gonna stay keep the bio view still gonna be acquiring the data. You're gonna push in the same type of volumes 25 another 25 to 50. Then another 25 75. Another, uh, 25 to 100 the same sequence. And this collective measurement at each time you inflate to those volume measurements. After all that's done, we're going to reinsert that Catholic because you can use the same Catholic for balloon expulsion testing. Reinsert it. You're gonna insert it to the 10 centimeter mark, inflate that 2 50 ccs of room temperature water, then you're gonna help them. Ideally, if you can get on to a remote or on a toilet, you're gonna disconnected from that. That Keep that that cable thing that we saw in the slide before, you're gonna help them get over onto the toilet Orca motive possible. Um, if you don't, you can also do it in in the bed position. Then you're gonna have up to two minutes, uh, to basically evacuate the balloon. Remember, no hands, no rock and roll and no finger manipulation. Let's see what you can do with your own, um, muscles on Lee. And we'll talk a little bit about blue Next, More about blue explosion test in the slides down the road here, the correct technique for acquisition is really important. Remember, always start the measurement area first, then asked, Instruct them to do whatever you're asking. Do you need a little at least one second prior to their instruction? You won't allow at least 32nd very in between each maneuver. But more importantly, you won't allow it to come back to recover to the resting tone. 30 seconds, at least a minimum. It could be beyond that because all predicated on the recovery, arresting, tone coaching, Um, you know you want to do that to a minimum. You don't wanna be know that through literature there's enhanced instruction or biofeedback and definitely influence some metrics within an erectile Manama tree, especially the push maneuver. So coaching try to do it very limited, because during the instruction phase of the indirect Manama tree, you want to be clear that they understand what you want them to dio by using that talkback method. So before we move on, is there any questions regarding the difference of the protocols between high resolution Air um, and disposable era we have one question. Do both protocols produce the same results? It's a good question. So there's two different platforms, right? There's high resolution and there's this disposable a directive. Manama Tree. Um, with with all the standards of lower level threshold and upper level threshold, each will get you to the same point. Um, it just looks a little bit different between wave form and very colorful plots. But the same results for the patient can occur on both platforms. Good question. Alright, If you have any questions, continue to put them in the chat. We will address them as, uh as we move forward. But some terminology with the disposable and erectile Manama tree platform again in vivo just means inside the body and erectile. Uh, baseline. So this right here adjustments could be made to any measurement in the study during the analysis phase, so we could kind of show a little bit of this, but say this. This window was over here. You see some pressure above and you see some pressure below. We want to try to get that is Aziz zero very nearest zero as possible so we can adjust this and you don't need. You don't need very much of this pressure. We just need a little bit of a few seconds to adjust for the an erectile baseline. So the resting pull through technique again. You don't wanna be pulling it out quickly. But you don't wanna be moving into slow. You want to do it as you pull the same fashion for each 154321 type of issue here is this again that interact a baseline over here above sixth. And as we go, as you see, there is little blurts of pressure as you pull to the next centimeter that there's a lot of nerve innovation down in that that near that sphincter. So you're going to see this transit? Increasing pressure, you know, kind of a lot of ways. It's a very poor man's way of assessing the the spinal reflex arc right there. But, you know, let you get back to a nice resting tone after the transit, increasing pressure, then you want to collect the measurement. You don't wanna be collecting it As soon as you pull through and you have this in that measurement range, you want to give it a little bit before you dio collect the measurement at each one of these depths again. Remember, you want to keep your eyes on here? We're on here. It's exerting the greatest amount of pressure. Your greatest home. As you see number two, um, exerts the greatest pressure over all these channels. So you wanna keep your Remember your eyes on our write it down on the Sharpie. That channel, two centimeters, um, exerted the greatest amount of pressure. The squeeze pressure. Remember, squeeze me and you're trying to hold it in tight, Tight, tight. You don't wanna let anything out. The same things occurs here as you do to pull through from 54321 You see this little transit increasing pressure when it's as you pulled to the next centimeters. So give it some time, get it to the resting tone, then have them squeeze real tight, you know, for five seconds. Squeeze, squeeze, squeeze for at each one of these centimeter depths The duration squeeze pressure again. Remember, back in the high resolution inter economically, you're gonna get this transit increasing pressure really abrupt. It's gonna and then we want them to be able to sustain 50% of this increasing pressure for about 20 seconds. So and then eso when? If you're going to use this metric and you're going to calculate the metric you want to report this in seconds, Um um, instead of of a qualitative measurement. But if you want a quantitative measurement, you wanna report this in seconds, the rectal and hip batory reflects, and this is a rare was calling it rare as this this one shows we did a sequence of 10 2030 40 50 and 60 Mhm. But as moving forward, I highlight using 30 only that matches the new kind of consensus protocol protocol London Protocol. So but here's a sequence of 10 2030 40 50 and 60. As you see as you inflate the balloon, you see this increase in the balloon, then an internal anal sphincter, or throughout the anal sphincter here you're going to see relax ation from resting tone, involuntary relaxation, then back to resting Tone can look in about 20% over at least. Uh, try to see this over at least three channels that this relaxation is occurring. And generally, sometimes as you increase the volume different volume marks, you'll see more robust, uh, rare response. So as you see the difference between almost none in 10. 20 all the way to 60 you see a more robust response in 60 before we move on to to push, maneuver and really kind of dissect into dis energy defecation and types of it. Does it Does anybody any questions about any of the terminology? Differences in the disposable and director Manama tree. Um, what are the keys to performing an analyze herbal pull through? Yeah. So the key is not going too fast. Especially some people may come in and they may have a some external hemorrhoids or even some internal hemorrhoids or rectal prolapse. So you don't wanna be pulling too quickly? Um, you wanted Thio pull gently. You don't do thio rough either. And then you also want to give it some time to allow that to come back to the resting tone, especially people who have anal fissures and all these other type of things. You want to make sure you get back to a nice resting tone before you move onto the next measurements. You don't want to kind of be like quick draw McGraw. You don't wanna be Just click, click, click, click, click To get through. Really take some time to do a good record. Uh, resting Pull through and squeeze. Pull through. But most important, the resting pull through, because that's gonna let you d market where you're eventually gonna tape three catheter in position for the remainder of the test. Okay, The substance. If you have any questions as we move forward, we're gonna look at a little bit. Why? The main reason we may do interrupt Manama tree is really to look at, um, do they exhibit dis energy defecation and the subtypes? If you, uh, we can you can also tease down to the potential subtypes. But there's four subtypes of dishonor. Justification Type one is really the primary one. That's basic where you have enough adequate interruptible pressure. Um, and then you have a paradoxical contraction of the anal sphincter. Type two is a derivative of type one. Just don't have enough adequate push force pushing force and interactive pressure, but you're still paradox of contracting. Take three. You have adequate, um, pushing force to generate enough interactive pressure, but an absent or incomplete anal sphincter relaxation and type four is where you don't have barely any generated adequate pushing, pushing force indirectly, then also absent or incomplete. Almost quiet, isn't you know, Speaker Response of relaxation? Here's a little schematic of what they would look like. These have done on a different type of counter, but really shows the picture of what the subtext look like. Meta Metric Lee Type one is is the goal. You know you have enough interactive pressure than anal relaxation. Adequate enough type one. As you see, the difference is there's this paradox. Contraction. They think they're actually relaxing, but they're actually contracting. And, as you see type 23 and four are a little bit of driven from the normal not enough interactive pressure here. Not enough anal relaxation here and really missing both on type four again, mostly dried from type one. Just synergy will be a response. Um, this could get up. You know, some literature shows up to 70% but primarily what you'll see is type one, um, dissenters, your defecation. If they are exhibiting this type of response, Meta metric Lee is disposal Mina Metric Lee in particular. As you see, there's different ranges, so this range right here you can see on the side you could toggle different ranges on the sides and make sure you keep your eye on what range you're actually looking at. The rectal pressure here is much smaller than the sphincter pressures, so the increase inside the rectum is adequate. Then, as you see they, whenever you ask them to basically push or have it simulate defecation, you're automatically going to get transit increasing pressure as seen on this blur per pressure going above the resting tone. But then they start to relax. If if it's normal, as you see, this relaxation pays its coming here, you see this relaxation phase that's coming here, here and here is going over at least three channels, and this is beyond the 20% mark from resting pressure. As you see it comes back up to arresting tone. Um, shortly after you ask them to relax. So wrecked, then rectal sensation measurements again. This is where you're slowly inflating it, you know, to MLS the second again. You can practice this in between patient, especially as your first learned. You don't wanna go quickly because you almost generate a rare response quickly. But you really just want to go nice and slowly and then you're in a first sensation, remember? That's when there, you know, you can wait to the TV show's over an urge. You have to go commercial. That Max tolerant means they cannot, you know, wait anymore. They gotta go right now. Remember to write down the Sharpie or just remember this number and we're gonna end up dividing that by four to you, Director of compliance portion of the test. So the rectal compliance portion, as you see where we say the person had a maximum tolerated volume of 100 we're gonna inflate the balloon to 25 m. Els, wait 30 seconds. Collect that measurement and another 25 to total 50. So you don't wanna be letting out. You just incrementally adding it. Wait 30 seconds to collect the measurement. Another incremental 25 MLS of their 30 seconds collected measurement than the last 25 increments. Uh, Thio 100 wait 30 seconds and collect that measurement. So this is allowing us to measure this This compliance measurements really looking for, um, compliance factors for hypersensitivity is really the key by one is doing this type of test. Then after over here, as you see on the screen over here, you're gonna untie a pit. Then after deflate it on, tape it gently remove it. Kind of lay it. I got a pillow or a blue pad right next to the patient. Increase it to the same incremental volumes 25 50 and 75 to 100 everything. And collective measurement by just continuing the same window collecting the measurement. And this is gonna allow the software to adjust from the outside to the in vivo or inside the body volumes. Okay, after that's all done, we're gonna insert that same Catholic so you can use the exact same one to do the balloon expulsion test the balloon expulsion test again. You're gonna need that. Why you wanna put it to you if you can get it The 10 centimeters on the demarcated on that catheter that gets it, you know, into beyond the line of don't you know beyond anal canal into into the rectum area and then you're gonna inflate that with 50 MLS of room temperature waters. Try not to do it too cold or too hot. A good rule of advice is just taking the water and to the sink and and put it filling the cup of water and setting aside while you do the 20 minute and erected Manama tree. So generally gets to the room temperature. Um, you want instruct the patient again comfortably sit on the toilet. You don't want them to be bending over. You don't want to be holding their breath. You don't want them to be, you know, straining so so hard. But again, you don't want to be rubbing their belly and no finger manipulation, no rock and roll and type of thing. You want them to sit nice and comfortable and try to expel this, uh, this point, remember, you want to disengage it from that that color little, uh, cable connector. So all they're gonna have is the catheter here. The blue will be inflated. The stop cock will be in the off position. We're not allowing water to come back out beyond the stop cock. And you remember during high resolution indirect in Manama tree you you know you need to have another commercial device to do balloon expulsion. You should not use the high resident director when I'm catheter to perform this type of this test. Here's a systematic review. Basically this highlighting some key parameters of balloon expulsion Testing. Is that the body position? Um, it's recommended. You could do it in a seated or the left lateral position. Basically, the r o C. Curves and show any difference. The blue volume standardizes between 50 and sixties. The contents is always water. Then the cut off for an abnormal balloon. Expulsion time compared Thio normal balloon expulsion time is 60 seconds. So what we're gonna do is this. We're editing steps and review a little bit here at the beginning, we're gonna zero the baselines. They know rectal balloon baseline. We're gonna just any pressure ranges if you need to see, um, to increase the deflections on the screen so we can see it. Sometimes they're very low. Sometimes it could be quite high. We're gonna just a measurement. Boxes were gonna verify all events are on there and any adaptations that needed to be done or they're accurate review the entire study. Remember, save save regularly is very important. Then we're going to generate a report for the interpreting provider. Thio review any questions about that before we open up? Hey, A normal study. Normal disposable interactive Manama trees study. There are no questions. Yeah, Jason. Okay, so how many? Get out of this one. I'm just gonna open up a normal study here. So as you see a couple of things when we first opened up the study itself, you're going to see the entire thing. Um, here all your measurements, and you see how this one was done. 40 minutes. You got your same toolbar Almost very similar today. Indirect one you got. This is the balloon. If you click on here, you're going to see the different type. If you want to change your ranges from 10 to 500 Um, if you and another thing, if you click here, if you only want to change this channel, you just click that off. And it would only change this. It wouldn't change them all. So, for example, if you so you want to put this 50 now you see is a 0 50 the state at 0 to 100. All right, the next thing what we're gonna do is we're just gonna open this up. I'm a big I tend Thio. Look at these in two minute windows. Aziz, you As you advance learning how to do this, you can choose different window timings. But I tend to look at in two minute window blocks. So the first thing we're gonna dio this is kind of pull this window over here, so we're gonna see this is the indirect. Oh, baseline. It's a nice, quiet area. But say you need to say it was over here. Had this little blur say it was You can a justice as you like, but you don't want this in that area. So this is what you collected. You would move this back over to wherever most of these are at all in the zero range. All right, then, at that point, we're gonna career mhm. Then we're going to analyze all measurements. All right, So then then what we're gonna do is now we're gonna move on to say, for example, this was all artifact, What we're talking about maybe collecting one outside the body. So this would be if you had a lot of artifact or a lot of movement in here. If you had that one outside the body, you would have no movement at all because it's not. It's just comfortably laying on a blue patter, a towel. So this one is very quiet, isn't nice and quiet, so we can use this one to move move towards through the pull through. So the first thing is the resting Poulter. As you see it's five, and then we Then we collect a measurement for about 10 15 seconds. Then we go to four. Collect another man you see starting you know, the the catheters placed correctly because there's a little posterior lying on the catheter. You want that line when you insert it that represent the posterior side, So jet. More often than not, you'll see pressure increase first on the posterior side because some of it the pubis reptiles is kind of sitting on the angle. And sometimes you start to get a little bit of this pressure as you're doing this pull through. So really important on the disposable catheter there is that there's a posterior line. You wanna make sure that represents our towards the spine. When you're pushing, when you're inserting the catheter, then we go to three. You see more pressure starting to come up through all the channels again. This transit increasing pressure. We let it get back, Teoh. A nice tone. Collect the measurement then too. You see even more pressure starting to exert, then eventually, um, at one. Over here. So again, we want to keep our eye on which which centimeter depths is getting the greatest amount of pressure. And then this one Channel one is exerting the greatest pressure at overall at each one around the same centimeter. Depth, post your aunt your right and left. So we're gonna remember one centimeter the next step. We're just gonna basically inserted back in 25 centimeters. Then we're gonna now ask them to squeeze, squeeze, remember, which means trying not to let anything out. Tight, tight, tight, tight for at least five seconds. I remember you want to start this measurement window before you instruct them to squeeze or do whatever maneuver you're asking them to do? The next one at four. And we're gonna go through all these 23 Then we're gonna venture in two and one. But you see says you pull through. You get that like that nerve innovation, that pressure response right there, transient. But then you let it come back to resting tone and ask them to squeeze again. So if you do all those, you're gonna now tape it at one centimeter. That's where they exerted the greatest pressure at during the resting side. The resting Pull through. Move on to the squeeze duration. We're gonna ask him to squeeze. It's gonna be for 30 seconds. Trying not to be silent. Do a five second count. Five seconds. 10 seconds. 15 secs. Patient knows exactly where they're at again. You get this transit increasing pressure over the resting tone. And this is where they need to sustain this type of pressure for at least 20 seconds. 50% of this pressure for 20 seconds. You see, this person was unable. Thio, perform that maneuver. The next thing we're gonna move on is to the rare and sensation test again. Don't let them know you're gonna be pushing air into the balloon. So they're gonna be pushing in quickly, deeply, quickly. Then we're gonna be looking for this thing in inhibitory response to occur. This is in a sequence of 10. Then 20. As you see here is an increase in volume in the balloon and it's decrease increased volume in the balloon. There's really no inhibitory response here. Here you see a nicer inhibitory response. And then as you work your way through this at 30 member, keep your eye on 30 and moving forward. You This is the only following an adult world you want to dio 30. And if this response look to say, this response right here was an abnormal response or equivocal response or inconclusive, it kind of looked like this. This one. Then you would want to do one more at 30. But again, remember, don't do that. Don't do another blown a volume until it comes back to resting tone or at least at least 30 seconds. So again, keep your eye on 30. But as you walk you through this as you see, they get a little bit more robust up to 60. The next thing we're gonna do is we're gonna look at cough, remember? We want them. Just do one abrupt cough. Um, this is usually in the squeeze measurement window. But if you click on this, you can. This is where you can change what it is. Sorry, you can change to put that as a cough it is. When you first open up, it will say squeeze. But you're gonna change that to a cough. You see, you got the bloom pressure. Even they make off. Then what? You see, she should see a more of a robust response in the annals finger. Because if this pressure is greater than this pressure, whatever content that would would be lying here, that this pressure would over overcompensate. This pressure and stuff would be sorry. This stuff would basically be emanated or evacuated from the body. So this pressure right here needs to be higher than this pressure to remain content. That's basically what you're looking for in the cough reflects The next step here is now we're assessing for disinter justification. This is a completely normal response. What? You're looking at you Have you asked them? All right, I want you to push, simulate, defecated in push, push, push, push, push. As you see, you get enough interested pressure. And then, at the same time, nice anal sphincter relaxation here. Well beyond the 20% mark as almost like Remember that schematic illustration in the slide deck. As you see, this would increase this decrease Exactly what you're looking for. And as you have them do three trials. It's often they'll do three different things. Like, you know, the first one there. Like, Oh, I'm not doing that. Just case I evacuated in the bed the second one there, Like, uh, you know, I'll give it a half try, and then the third one, they'll eventually end up. You know, give the big response. As you see this one, this interact. Blood pressure is much higher than this one. So, you know, you could see they put a little bit more effort into this one also. You know, you could sometimes see a response right here. You ask him to push, push, push. They may exert so much pressure that they overcompensate. Your tape job in the catheter comes out. So it happens. You'll see this, and eventually we'll just stay flat line throughout. So you have. You know, I have to recommend every time in between, um, push maneuvers. And you want to explain this to the patient before the test starts? When you after you get done with the push maneuvers simulating defecation. I'm just gonna looked up your down or the blanket just to verify catheter placement and be able to annotate if there's any content that were expelled. And so sometimes you may have to reposition it at that same sentiment or depth. You've done the rest of the test with Thio continue on during the push maneuvers, but say this was an abnormal response again, it is mostly type one remembers, dominated by type one dis energy. You'd have this type of interactive pressure response. But instead of seeing a nice relax ation here, you'd see this paradox, that contract, and it would go up to this range and come back to the resting tone, and all these channels would be flipped over. So that would be what it would look like if it was a NAB normal type. One response type to you would you would have this response. Nice relaxation, but this interested pressure would be inadequate. So if you're looking at for at least 40 to 45 millimeters of mercury pressure, each one of these dots represent 20. As you see, it's on a scale 0 100. So 2040 60 8100 so didn't get much beyond the second that this would find the type two. Type three is that you have this nice, robust response. But this would be inadequate or incomplete of the 20% demarcation line. Then type for this would be well under that second dot if you're at 0 to 100 then this would be incomplete er, APS and almost quiets and nothing really happening. So these would be the, um, depictions of what, during simulated defecation during a disposable type of Manama tree. Uh, test the next step here, we're just gonna basically, slowly inflate the balloon to MLS and second Again, Again, we want to instruct the patient what these definitions are first sensation urging maximum tolerated prior to test. You can kind of reinforce it before the section, but you don't wanna coach that or give enhance instructions or any biofeedback Thio, You know, basically, do intra bias towards this section. As you see you inflate the balloon slowly. You see this nice ramp up here. So the first day informed us at 30 ml that day. First, feel it. Um, you know, that means that you can go to after the bathroom after your TV show. Urgent 45. That means I gotta go a commercial. But at that volume that maximum tolerated, they did 95 here, Um, they got to run to the bathroom right now. As you see right after they say that you even before you d market this on the screen, you can just deflate the balloon. It abruptly decrease back to know bloom pressure at all. I have to recommend not using the syringe to pull negative pressure. If you remember back from physics, the loom in line of the catheter is much smaller than the 60 ml syringe. So, um, that tends to create a lot of negative pressure. I've just naturally let it deflate. Um, it should dissipate relatively quickly. As you see here, this is on a two minute window screens. So this is about this. Took about 3 to 4 seconds to to completely deflate. But remember, this is at 95 so we're trying to get four data points, so we're going to do the rectal compliance. Pardon? And you can again you can kind of round up to make it a little easy. Numbers. We inflated the 25 m els and then collected a measurement for about 10 or so seconds. We inflated another 25 MLS. You see, the stepladder happened here. The 50 MLS 30 seconds later took a measurement. Little bit. Mawr. Does this 75 member, you're continuing your not deflating. You're just continue to sequentially increased the volume. Take a measurement, then the last one just round it up to 100. Um, the last measurement. And then right after that's over again, Just open up the stock cock. Trying not to use a syringe and let it dissipate naturally. Just took a little about 67 seconds. All right, then, the next step you're now you're gonna untapped the catheter, and you're gonna gently remove the catheter. Just lay it nice and comfortably on the blue pad or towel. You. Sometimes you could lay it right next to the patient. If you have enough room in the gurney or you can lay it on your meta metric cart, you are stating the steel cart whatever using right next year. But you wanna lay that on a blue pattern towel and here again, we're gonna inflated the 25 Collect the measurement. Great increases. The 50 collective measurement 30 seconds later increased to 75 30 seconds later Grab, gather measurement that increase it to the last 100 to make it 100 collect a measure. After all that's done. Now you can, uh you can save the study, close it and to study. Then we're gonna put that catheter back in. Remember, trying to get all the air out as possible. Put the catheter back in to the 10 centimeter demarcation line that we're gonna fill that balloon up with 50 MLS of room temperature water. Um, we're gonna turn to stop. Pack off. Disconnect from that. That that cable connector eight assists them over to a CA motor toilet if you have that in your room or they could do in the left lateral position. But if you leave them in the bed is always a good practice to put the rail up the same case, Any chance of rolling out or anything like that? I highly recommend if you do it in the bed position as the catheter lays on the bed at towards the end somewhere the catheter. I would just take it to the bed so it doesn't fall. If they're able to expel. Sometimes it may fall out off the gurney, so I would just take it to the gurney. And also I pulled the gown or sheet back down. And remember, we always recommend up to two minutes that really gets up. Thio, you're you're able to get sensitivity. Specificity. All that means is that you be ableto recognize up the 90% of the people who may have dissenters. Your defecation defined by the Rome criteria. So two minutes, but at 60 seconds is the demarcation line to be normal or abnormal. If you're if they're able to expel it out, that's great. But if they're unable to expel it out, all you're going to do is go back over there after two minutes. If they're on the comodo toilet, open up the stop cock gently removed the water into the syringe. It a kind of burp when, when the When the water. Burkes. You know it's just trace amounts left mostly left in the Catholic or not in the balloon. Just have them gently stand up and gently removed the catheter in the left lateral position. The same thing on through the stop cock. Pull the the water back into the syringe into a burps, then gently remove it. And then that catheter could be disposed. The patient could get dressed and then leap. So the patient's gone, And then now we're gonna look at the report itself. This will generate the report, have the person's name. These are all made up names on here. Um, so this is the report will look like this. I'm sorry. I get the group decidedly just moving in sync so I could get to the side here. Okay, so on the top of report, you got all the demographic remember during webinar one and some of webinar to that. These are there's only Asterix air required on the report. But I highly recommend putting all this information in. Um, this looks like a complete report, and then you don't have to do it over. It will populate by itself, you know, symptoms. You can You can write this stuff in here also or the and then the impression by the interpreting provider. Then we're gonna some quantitative data very similar to the high resolution indirectly Manama tree. But this time we're gonna get a resting tone. Uh, pressure of posterior left and here. All right, we're gonna get an average at each senator. Your depth that you see, there was really trace amounts of five and four little bit Maurin three. But you see most of the the pressure is happening in channel two and one we selected one. And as you've seen right here that it was, it did exert the greatest pressure, the average overall and even the absolute number. The squeeze member 54321 this is what they generated, um, relative to the resting pressure. So these, these are not absolute or relative to the resting pressure values. Cough right here just shows you to increase what the pressure was inside the anal canal itself. And if you want, you can go back and look at what's happening. The bloom pressure to see if this was a t least one times greater than what was happening. The blue pressure. The ratio is really 1.5, but it's really more of a qualitative response. Generally, we always right either normal or suboptimal and annotating whatever may or may not be discharged. This is a summary of looking at all these above. I don't use this very often, but it is a summary looking at these first three, uh, data tables. The next is a simulated defecation respond to see it's a negative number because this was a normal response. So this is basically the mean rectal amplitude and a minimum annual canal relaxation. So you this is sometimes called the simulated defecation differential. Often when it is when it's when it's normal, you're going to see a differential that is negative. Then the next step down is the anal relaxation. As you've seen, um, posterior left here and right, you see a huge amount of relaxation we're looking and we're looking 2020% arm or on. Do you see almost almost complete relaxation throughout all four channels for the response? Remember, when they're doing this, we want to make sure it's at least currying whatever is occurring, at least in three of the four channels to make a good evaluation. Thes air. Just plots of the of the same data tables at the top, the resting tone, um, symmetry to see if it's where the pressures that you see in two and one, they're pretty much equally spread out, especially one on this one. The interior side on here looks like it's not generating as much off that squeeze force compared to the posterior and the right and left as you see one most is mostly, uh, symmetrical throughout all quadrants of the, you know, canal again. Here's a squeeze profile you can see from the left and turn right where the millimeters of mercury pressure at. I don't use these very often, but these sometimes they're nice to look at, especially if you're seeing some discordance throughout the tracings itself. The next one eyes the cough profile again. We're just looking more of a ratio on this one. So this one I don't use that I don't use very often, Um, this is the same thing. The vector plot. Seeing a symmetry again. One. It looks like it's pretty much symmetrical throughout all quadrants compared to the three looks. Okay, but you look at 54 and to some areas, generating the general primarily generating all the force. All the pressure during that response. Cough act, your profile. Same thing. Don't use that very often. Then the last part of the report is what we're looking here is at the rare part, we basically shows you the percent of drop. So we're looking at a certain percent of drop and it shows you his present or absent. And if it goes beyond that point of the minimum level threshold, you'll see a present response also right here and then the rectal sensation that shows you what they self reported compared thio the normals. For this type of catheter design, you can self report and the rectal compliance here it shows you 25 are sequential order. And what This is, really that this what what rectal compliance is is really the Delta pressure over the Delta volume and what we're really looking for in healthy controls. It kind of this rides is like, almost like a linear line. Um, people with constipation that have normal sensation is really close, a little bit above the normal healthy control values. But this abrupt line up here, if it's abrupt slope and it's generally in this range up here, it does have some evidence that it's, um the compliance is towards more of mega rectum or hypersensitivity. All right, and then so in summary, you know, in summary, basically, enhancing your knowledge of anorexia terminology does improve your technical acumen. regardless of what platform you're using, understanding the terminology and how Thio explain it to the patient. For them to maneuver through the test will improve the quality of your study. And that just comes with experience in doing more and more of them. And performing a consistent editing protocol and acquisition style does provide does generate better report. So if stay within the same sequence throughout each Manama and this goes for all Manama tree, just not a direct of Manama tree Similar. What we said during the South Geo Manama during those webinars is having a very consistent editing protocol. And acquiring protocol does generate the best quality report. Appreciate everybody you know, attending these webinars. I think they've been very useful and hope they provide, um, Lisa basis for you to perform, um, really high quality meta metric test and I'll take any questions that anybody may have. Hi, Jason. You said that high rez and way former reached the same endpoint. The high resolution probes are very expensive and require delicate handling and expensive repairs. If they're needed, are you more likely to use a disposable probe or, um, in particular situations versus a high resolution probe. That's a great question. You say that is the most debatable question indirect in Manama Tree. Um, a couple things, I think. Yes. So both get to the same end point. If you're using the focal point of the London Protocol, it will both get to the same end points. Um, one thing I would look for at your institution is what type of, uh, high level disinfection capabilities you have that may also determine which which platform you go over towards. Um, some cost does sometimes play evolve in that, but infection control tends to have the highest weight in these decision making processes. Um, so, um and also remember, with disposable, you can use the same one to do balloon expulsion and, um, interrupting monetary high resolution. You you need a different device. But I would say there's some advantages towards the high res is that, um, that the disposable doesn't have the high res. You can really look at a little bit mawr at structured areas. Um, that may be causing some of the pelvic floor dysfunction that you cannot do that in disposable catheters. So I would say I would look at the infection control capabilities. Patient population. You may be looking at, um and then also overall costs when you're actually looking at what platform you may do. And I would say most places that you indirectly Manama tree the cost of having the module that does disposable one is very low, very nominal. So I was. Most places around the country do interesting geometry often have the capability to you both in different situations. Great. It's like I have one last question. Jason, what are key aspect for assessing disappear This energetic defecation with disposal in Iraq? Al Manama Tree Yeah, I think there's three main ones. I think the catheters placed correctly. Eyes one, um, number two doing a good explanation of what you want them to do prior to the test starting and the third one going back to Webinar one. And we also said it in, uh, Asafa Jill Webinars. And if you ever hear me chat, this is basically I say this all the time is winning the room within the first two minutes. And what I mean by that is making sure the patient feels very comfortable to simulate defecation or push in the left lateral position and basically in front of a stranger, even though contents may come out. So you wanna make them feel comfortable that they have. They're able to do that without having this embarrassment factor leading into that. Because I think if you win the room in the first two minutes and you allow them to feel comfortable with you and do this partnership with them be their coach, you'll get the best response even regards if it's normal or abnormal when they attempt to do the push maneuver. Yeah, great. Well, thank you, Jason. This concludes our webinar exploring conventional studies with disposable Aaron probes. Thank you for participating in our webinar Siri's. If you've missed any of the previous Webinars, please go to diverse a tech healthcare dot com and log on to divers attack you to watch previously recorded sessions. Thank you and good night. Created by
