Chapters Transcript Video High Resolution Esophageal Manometry – Start to Finish Webinar Series (1/4) Review the related anatomy, the setup process and probe calibration, as well as proper technique to place an esophageal manometry probe. Yeah, until mhm Hello and welcome everyone. Diversity of healthcare is excited to present our webinar Siri's high resolution esophageal Manama tree from start to finish. I'm General Schmidt, the marketing director here, a diverse back health care, and I'll be your host today to provide you with a little background. Our education team was motivated to create a Siris of webinars that breaks down Asafa Geo Manama tree for any user. Regardless of experience, we will walk you through the fundamental or being Chicago classifications, editing normal studies and finally discussing advanced editing techniques and abnormal studies. We hope that you find value in each of the webinars we're presenting this month. Today's topic is anatomy procedure set up and proper probe placement. I'd like to now introduce our speaker for the Siri's Jason Baker. Jason is the co motility director and the director of clinical research at Atrium Health in Charlotte, North Carolina. He's a frequent presenter at national and international annual scientific meetings, and very recently he was elected as a council member for the American Narrow Gastroenterology and Motility Society. Ah, few notes before we begin, your microphones have been muted for the duration of the Webinar. If you have any questions, please send them at any time via the questions box on your go to Webinar panel and we will answer them during the questions and answer session at the end. Due to the popularity of this program, we'll do our best to answer all of your questions. With that said, I will turn it over to Jason. Well, thank you very much. I'm very excited for how many people have elected to spend an hour with us going through these, uh, webinars. I think there it will be very useful, especially in your practice and even even just learning this process. We broke it up in a four different modules, one just looking at the anatomy review into set up process and proper placement of the catheter and some partnerships with the patient that work them through this particular test on. But as we go on, we're gonna look at the Chicago classification and all the metrics that go involved with that. Then we're gonna do some revealing of a normal study, then reviewing of some or abnormal studies. But as we work through this, I want you to remember we have one of these modules or webinars is based around on Lee High resolution Asafa Geo Manama tree. So, for example, the objectives for this webinar is that we want to describe the anatomy of a swallow. But in relation Thio Ah, high resolution Asafa Geo Manama tree we're gonna describe to set up of the software we're gonna Then we're gonna look through the art of the proper placement of a catheter. I think this is a true art. Um, it's more than just inserting the catheter into Transnet easily trans normally. But I truly believe there's an art of doing this. Especially if doing many, many of these over last 20 years, then more. One of the most important thing of this this webinar, is to truly understand There is a partnership between the Allied health professional and the patient, um, working, working through and Asafa Geo Manama Tree and I really encourage everybody to develop a good regimen of building a partnership between both parties. So a little bit we're gonna start with the anatomy. The salvage of length is up to 22 centimeters. Give or take these air some broad ranges. Um, view. Yes, it's about 16 centimeters from the chief, and then if you place it through the narrow, you gotta add another approximately four centimeters. Why is this important? Is that when you're placing the catheter, depending when you look on the catheter, if you're feeling resistance or not, if you know the depth where you're at in the rough estimates of these length of these regions, you can help troubleshoot just by knowing the depth where you may be at. So keep these numbers in mind. They're rough estimates, but it allows you to troubleshoot in real time placing the catheter so there's three phases of the swale. There's an aural phase, which is voluntarily, there's a fair and geo phase is really important to moving the fullest towards the amount to the to the esophagus. Then there's this Alphaville fix. These are where there's contractions, both circular and longitudinal, and, as you see, there's different places around the esophagus or that generally range within destroyed it and smooth muscle. And they're both important for moving. Whatever the Boulis is from the top part of the esophagus, down through the bottom part of this obvious into the stomach. So a mechanism of the swallow is important Understand how this all happened? So if you if you think about eating a piece of candy right now and every chewing it, this is the first. This is part one. This is where you basically masticated in that that food or content you put into your throat to formulate the bolas, the basic. Then the next part is where your proposal phase, where you're taking that now bullets or that piece of candy and you're pushing it towards the back of the throat. And then the third phase is where this epiglottis now is starting to move over from protecting the respiratory region and allowing, um, the esophagus to start the hope of or stuff that can move through their like this. Bullis. The fourth phase Is this this fair in jail phase? Where is the pressure? It's pushing down and pushing this Bullis through the upper stop Agios finger. Then the fifth phases. Now it's in the esophagus and these contractions takeover migrating the bullets from the top part of the esophagus down to the digital part esophagus into the stomach. So if you can imagine, all five of these phases have to occur when you ingest the meal or any contents that formulate into Ebola's. So the Upper South digital thinker is quite bearable but doesn't really get too much play, I think in Asafa geometry, but it is important to understand at least this common concept that when when it's at rest is contracted. But when something goes through there like that piece of candy that is going through there, it will start to relax. Then it would migrate through that upper South of deals thinker. Then it will contract again. And, as you see on this varying types, well off, uh, picture diagram on top, you could see it contracted. You could see when it opens, it stays open. Then it closes that because the end of the swallow but the diameter it's really tight when it's closed, but when it opens, it gets larger than it closes again. So this upper South Agios think since your opening and closing when the bullet goes through there, it's all about within one second. The pressures that quite variable could be very low, very high, Um, but also the upper soft deal is important for protecting from content migrating from the esophagus into the fair in jewelry for aspiration, but that's opening and closing. This is the most important things opening, closing General Kerr roughly within one second. So this is important to know these kind of brief concepts of the physiology of the upper stopping deals picture, even though it's quite rare. The next thing, we're gonna look at these these certain muscles or two in particular, just circular and longitudinal muscles. So the launch into muscles, basically we'll shorten and the circular muscles will contract. And as you see on this, this first pick the grandma on the right hand side Green means low pressure. Red means high pressure. And this certain bullets right here. You see, the pressure is trailing, the bullets trailing the bowl is trailing Ebola. So basically, as you see down here and another green right here is, um is the circular in the red on the outside is the longitudinal. So as this Pulis comes down, the longitudinal muscle fibers will shorten. Sorry about that. And then the circular muscles will contract behind it, pushing it down, and as another one will happen and it's sequential order until eventually gets into the stomach. So these air the general physiology of the swallows. What? The muscle fibers, what we're looking at during the south of Geo Manama tree. So the lower esophageal sphincter, in contrast to the upper esophageal sphincter, gets a lot of recognition. So especially within Asafa Geo Manama tree so that Lee s their lower esophageal sphincter region is where basically the esophagus intersects with stomach. The top part of the Alliance region is in the diaphragmatic hiatus and in the lower part is in the abdominal region. And this is when it's when it's been without any evidence of high or hernia or separation between the L Es and diaphragm. We're gonna We're gonna look closer at this here a second. But there's this certain ligament of all these anatomy figures, the ones I would the one I would probably you know concentrate most on is is about French villa Santa Jill Ligament. So this allows the diaphragm and L E s to move freely during swallowing during respiration, but also allows a barrier for stuff migrating from this gastric regent into the esophagus. What it is in normal region are normal, um, tightness without having been compromised. Yeah, so here we see on a Manama tree type of depiction here is that here's Delhi s and we're gonna talk about a little bit about morphology and webinar to, But when the diaphragm and Alyeska right on top of each other little, consider this Safi Jill mythology Type one, and this would be normal. It gives you the best barrier from having any contents move from the gastric region into the Asafa Geo body. I'm sure serving that on then when you take this deep breath and some of you have someone take a big, deep breath in, what will happen is the pressure and the thoracic cavity will be decreased or negative. And then the pressure in the stomach area will be greater. And as this right, because they call the pressure inversion point, we'll talk about this. Mora's this Web banners go on as you move it from the bottom, the bottom of the screen to the top of the screen. As you move near here, especially with morphology type one, you'll see this pressure immersion point where the pressure and the harassed a cabinet gastric regional flip on top of each other and it looks like a diamond. So the initiation of the swallow is when the bullets with upper esophageal sphincter opens, allowing that the goal is to come through. So after basically entering, leaving phase four of the swallow into phase five of the swale approximately two seconds after the U. S has opened, the L E s will start to relax, and this will generally go for about 10 seconds or so. And this is where we'll eventually measure that. We'll talk about the I, R. P and Maurin Webinar too. But this is basically the region that we will measure that integrated residual pressure act. And generally you know that the stenting of the the swallows over you'll see the basil pressure right here. It will basically relax. Then it will come back. Teoh A little bit of higher pressure right at the end of the swale or the pair of salsas. Wait. So someone someone has a high earning and looking back. Remember the slide? Few back about looking at the anatomy of all here. Is that ligament right here? You see it nice and tight, almost like a shoestring. It's not allowing anything to move from the top part of stomach. The fund is there into the esophagus. In contrast, you look on to the right. You see that the shoestring now is a little bit looser, and it's allowing the pressure force of the stomach to move into the esophagus. But this will also have to keep the diaphragm near the stomach. But then l e s will be moved further into the Asafa Geo body. So there will be a separation between El es and the diaphragm. So this is the importance of this ligament. Um, right here and meta Metric Lee, this is what you see on a height or hernia, as you see now, compared to a few slides back of that morphology, $1 morphology is Maurin the type, uh, to A to beat areas that and that the lower esophageal sphincter is now and Maura proximal in the south of your body. Then the diaphragm is lower below the Delhi s. So you can kind of see the diaphragmatic pinch these pressures right here during inspiration and respiration. So here is that someone is taking a deep breath and you see the pressure go down negative. There's a greater pressure in the gastric region. So this meta metric Lee, this is what you would be seeing. Uhm hyo hernia swallow so soft A geo clearance. Um, there's 33 things that help primarily impact esophageal clearance. There's gravity. That's why we end up doing these wadis. The Chicago classification ends up having to swallows in the supine position. Could you won't really take gravity out of that To see when you challenge the esophagus with different type of bullets is what the swallow depictions look like and all the other metrics of the Chicago classification. But there's gravity. There's primary parastatals is that generally comes with the initiation initial swallow, then secondary peristyle says that may follow, especially when people have brief lies. So primary prayer stalls is anybody most of people who have been doing Asafa geometry for some time. This is the swallow that occurs when the bullet enters the Asafa geo body. So it begins with us, relaxes again. The contractions last up to, you know, up to seven seconds. The speed is roughly 44 half centimeters per second. The amplitude right in the lower south of geo body. They called the trough. This is the top part. The bottom part. This is all smooth muscle, right here will vary. The top part will be much lower pressure. In general, the bottom part will be a little bit larger. And pressure hiring pressure. Um, it all MPs roughly within from the top to hear the top to the bottom here about eight seconds. But from the time the bullet's comes in the mouth through the south of deals Frank, this finger, the primary Paracelsus into the stomach. That's roughly about 10 to 15 seconds. So look about the physiology of Bulls clearance, because I think this doesn't get a lot of a lot of recognition. I'm just gonna go back. One slide is that there is this color formation where you can get a qualitative view of bullets, Clarence. But realistically, you need to look at the wave form, and I'll recognized quite a bit. Is people stay with the color depiction and don't really spend too much time on the impedance wave form. And this is really where you can find out if there's bullets, clearance or not through the Sava Geo body, but and we're just going to come and follow this cartoon to this, like conventional wave is when the bullets comes in. If you look right here in the middle. You got the impedance channel separated? Um, depend on what type of Kathy you got. What? They're separated by a certain distance. Gently two centimeters and then type one face One is the bowls that's coming through As it starts Thio, enter bypass one of these impedance channels. If it has a lot of irons like compared to like a sailing or anything like that, that is the recommended choice of doing this is sailing. That's where all the research has been done. But there's other products that institutions may use. But as it is, if there's a lot of ions, a lot of resistance as it passes one of these channels, you're gonna see a a dip in the conventional wave, usually about 50% below. Whatever the baseline is is be about right there. Then, as it passes one of these impedance channels and you're going to get the page, uh, stage four of this body, it will go back to wherever it is that baseline and stay in quiet us and until something other bullets comes through. So it's really important when you're placing the catheter to use a distilled or sterile water, then add sailing after after its place. Because if you sailing for the whole past that you may have some challenges looking at. Especially there's residual sailing left over. People have abnormal Sewall's. It's sometimes hard to evaluate both clearance, and generally it has to occur, um, in the bottom two impedance channels, and we'll talk more about this as we review different studies and weapon are three and four. But again, here's that baseline. It bypasses the channels. Passing it that it bypasses goes back up to the 50% threshold over two channels. Now we would say the bolas has cleared. So at this point, um, way have any questions at this point as we move forward through the anatomy? Um, lecture of that. The Siri's slides of that nature. Any questions about, um, those slides? Um, Jason, I have one question. Are you able to collect data? If the catheter does not transfer through the high, it'll Maria, it's a good question. Um, sometimes you're just, you know, even with, um, some techniques and some things that have worked to help people get catheters beyond that, Sometimes you just cannot, and we're gonna talk about the importance of the sent at least three centers below into the gastric region. But you can use, um, the height. The height is as a gastric baseline, a studio gastric baseline. But you can collect at least Asafa Geo body US pressures in a qualitative really view of the Elia. So in our practice, we would continue with the test, and we wouldn't. We wouldn't forgo doing that. But understanding that you have to take the l E s in the relaxation of El Es with a little bit of a grain of salt. Okay, I do have one more question. Um, could you please, uh, just repeat what you had talked about using distilled or sterile water versus normal saline? Yeah, So when you're placing the catheter during the original placement and we're gonna talk a little bit about the proper technique a place in it, you should use distilled or sterile water. Sterile water tends to be a little bit less expensive and more readily available in the health care system, but or you could buy distilled water because those two type of waters do not should be free of any iron, so there should be no resistance going beyond those impedance channels. When you're placing, then when you after it's properly place, you add the saline or another couple sailing because now, like you're basically introducing a, um a a bullish with Maw Ryan. So you know where there was no ions to when there was irons. Because when you get to start to have abnormal studies, sometimes there's some residual that sailing left over in the Asafa Geo body or on the catheter. Sometimes it could make it a little bit challenging. Checking for bullets clearance. Alright, so let's let's go. Let's work our way through the set up of the stops Geo Manama tree. And this is important to do to set up, I believe, before the patient gets there because as you start the partner with them as we work through some, some techniques I've learned over the last two decades is that eye contact is very important. It builds confidence and partnerships, so I think setting up before the patient gets there isn't really important for more of a partnership with the patient. But this is what the software looks like up in the right hand corner. But we're gonna select versus this patient management. There's some other items in here that that you could do with the software. But for just set up, we're gonna go to patient management. You're gonna get a window like this. We're gonna select new patient over here. It kind of looks like a medical chart that becomes where we're gonna need. You know, put stuff in the red Asterix are the one things they're required to move forward. But there's a bunch of other items you can do in here in the sense, if you want to start idea and different things or if you want your doing some for researchers, just I'm just re clinical. You could start tagging these things. But just for a sense of setting up a study that read Asterix are what are required name, date of birth, workflow. You know, you could set of what type of workflow you're you're gonna go into about. That's more of the study protocol. We'll go through tomorrow or next week's webinar about a standard protocol. Um, the catheter that you're using, you may have 12 or even more catheters, and then a study tag. You can in general too, Eckel Asia and all kinds of different things you can label here on the left hand side is basically the repository list. You got three different. There's zero ones. Zero basically is one of the studies that have been acquired. One. Let's say there's one ready for review and then then the other one. If there's already a study ready to have a report generator. So again, this is the set up they have. They have a toggle windows that drop down window. And as you put these in here by adding these, you can add different work flows by these, um, Asterix type of thing right here you can then you, as you go through when you're choosing the type of workflow you want, Maybe some people are doing peas and adults, or whatever it may be, you can click down there and change the workflow that you're actually using. After you do all this, you always remember to hit save so the supplies require. This is the stuff that we've used for many, many years. So there may be a few other things on here. Um, you need a 60 ml syringe. I also use I obviously don't use a 10 ml syringe. I think it's a little bit easier at times. Thio see it because, as you see, I'm wearing glasses right now, so I'll often use a 10 ml syringe. But having a 60 ml syringe is the common syringe of choice. Um, some type of water soluble lubricant, K y jelly or our surgeon loop. With that type of nature, you need some cause maybe a towel, a glass of water with a straw. Take your sailing. And if you're gonna use this is swallows, you're gonna have that available. Awesome. Yeah. So talking about the art of the Manama Tree Catholic Place and I truly believe this is an art, especially the better you get. And at it, I think it does become a narc. It's a choreographed movement. Often most places, um, perform south of Geo Manama. True is only one person in the room. So it becomes a choreographed movement. As your arms are moving. Your using your touching, the mouse or the screen, you're helping the patient. You're grabbing things. So the better you get at this becomes almost like a play on Broadway in a lot of ways, but I like teach. This is, I think it's very important. All my staff I've had over have been blessed to be a partner with over the years is that there is a pre procedural homework. So everybody is required to review these type of records and because it gives you the best opportunity to place the catheter smoothly, quickly and the first try. So we we require, uh, past medical history mostly require the first the order ordering doctors recent medical note. Generally to be, we want you have trouble swallowing solids, liquids or both. Did they have any previous esophageal surgeries? Have they've had food imp action in the last year? So how many times have they had that endoscopic Lee taken out? What their symptomology is that heart burns chest pain? Is it? Glovis is an upper abdominal pain, Uh, in the duration of the difficulties. Woman hasn't been happening for one month, is it? It's been happening for a lifetime, or it's been happening for a long period of time. We don't know all that before the patient arrived for the text. Other things that we want to review, we want to review the previous upper endoscopy this allow us to know if there's the event. Was there obstruction on the upper endoscopy? Do they have trouble by passing a scope through the L. A s generally about strictures and narrowly of the sovereignty of body. Was dilation performed? Um, we're a believer, and I've been, I think this is very good to have in your practice. If someone's been dilated, you should have some extended period of time before you do the south of Geo Manama tree because the dilation may impact the vigor of the of the Paracelsus way. So that changes, then it's not a distinct number, but I would go back Thio your you know, your is a physician or your team. Go back to your home base and just asked what type of time frame would be once to refrain from giving the south geometry after a dilation? Um, if they've had a soft a gram, make sure you know, you know, qualitatively understand how to read them. But more important is just the shape and the coordination of the swallow during during as a swallow the barium, because this will allow you to have very much idea if there's any gonna be an issue swallow, placing the Katherine. So here's the basically an image of a barium swallow. As you see right here again. Remember towards the anatomy that around the l. A s region that brother, you're going from the narrow your roughly between 38 42 centimeters. So, as you see you say, Well, it's about 42 roughly around 38 I see a little bit of their on the barren swallow. I know I may have some regurgitation or a little bit of tightness, a little bit of challenge getting through there. So I have to use maybe some different techniques to bypass that region. The traverse the catheter into the stomach. So seeing these damages before they come, you automatically have a head start on the challenge are no challenge of placing the Catholic, so preparing the patient is very important. This could be done through a flyer sent to them. Um, but even though when they get here, there's some also preparing the patient. But inside your flyer, and also when they arrived at the lab where they're gonna have the test, you want to describe the purpose of the test Very 23 sentences and generally in a very low, greater than eighth grade reading level for health literacy purposes. But you want to see what the purpose of the test if you want to be very honest about the length of the procedure, even though they may come in the block of time is for an hour, the procedure itself may only last 20 to 30 minutes. So you want to say you wanna that generally lets them feel because they're gonna know they're gonna be there for an hour? But the procedure itself may only take 20 to 30 minutes. What the sensations likely to experience? If you had one, you could talk more personally. Um, if you haven't had one, you could talk to experience of you doing these or just by your through your mentor or whoever. Proctor you what you've heard through your prompter ship, you wanna go to the risk of the procedure? Some places do you get that? Some people do not go back to your home base and find which method would work best for your regulatory institutions. Patients should have nothing to eat for 4 to 6 hours. I'm a big person on six hours. Because this data comes from the gastric emptying literature, about at six hours, at least 95% of the contents are gone in a normal gastric emptying phase. Um, you want obtained their history, you know, present symptoms. What they're feeling now. If they've been exasperated from when they saw their doctors have been new ones, the medications withheld depends on your home base in your physician. Some people hold different type of medications prior for 2 to 3 days. Other people do not something you have discussed back to your home base. So placement of the catheter it's This is a really this is where the art form comes about. So I I always before I placed a catheter. I always have them. Take one big sip of water, have them swallow once and only once and gently for a man. I'll look at their Adam's apple and then for a woman. I'll look at the back of their job because remember, from the physiology of a swallow, the upper esophageal sphincter will open and close generally within one minute on one second. So if the Adam Apple basically comes out, one second goes back down in the jaw line kind of comes down and goes back up within one second. I know there's really no impact of them. Their Upper South Agios think they're opening. If it doesn't, it looks like there is a little longer. I know when I'm pushing back on the catheter as they get to the back of the throat. I need the wait a few seconds as they start to take the steps of the water so it gives you. It gives you a key. How fast, or how slow you may go. So starting the placement of catheter, some people use anesthetic. You comply that either by a Q tip or a syringe pushing into the air, Um, and have them sniff back, Um, really important here. If you do use anesthetic that make sure you look at their drug allergies before applying that and even ask them. Are they allergic? Any, uh, topical anesthetic? And if not, if in many places. Also, just use surgery l and K y jelly and bypass the whole, uh, anesthetic phase. But that's something your team should discuss. You want to keep the head nice and straight the chin nice and straight looking straight out somewhat of a little bit of flex position, but you don't want it all the way down just slightly down kind of opens up the nasal passage slightly. You wanna slide the catheter into their Nair and then you wanna as you get about 8, 10 centimeters back again, there will be holding a cup of water in their left hand with the straw. I recommend a top on astrologist in case it may spill, and you don't have no water for them to swallow. You wanna gently push back, But now you know, and how fast or slow you need to go because of that, that practice well, And plus they also feel very comfortable They haven't had anything to drink in a long period of time. You wanna push back into you, you feel a little bit of resistance. And as you get towards that us and at that point, you want just you wanna have them still always start taking sips of water one at a time, continuously, until you hit you till you have them stop drinking. So again, you're gonna let him know there's a maybe a little bit of gagging. So they're aware of that before you places in. Then you're gonna traverse this catheter straight down as they take a little sip. As they sit, you move. As you say they sit, you move as they sip, you move. And basically what I do is I get about 40 centimeters or so. I have I have them take a break. I have them take a big, deep breath in. At that point, the most gagging will happen up here. Here will be a little bit less gagging. I'll let them know. Now we're gonna move it from the esophagus into the stomach and basically a few more bigger sips of water. We are down. What you're gonna be looking for on the screen is that you're gonna look for the band of two bands of pressure. You're gonna find the band of pressure of the top, which is the first daffodils. Think you're you're gonna find the band of pressure on the bottom this lower esophageal sphincter. Often they'll be swallowing continuously, just trying to get used to this way. Always give them about a 55 minute window just to get acclimated to the catheter. Eso don't worry about them continuously swallowing at the beginning, but you can see a couple of tricks is that before the eight. As the swallow phase comes down, it will end. Then you'll see the Elia start to contract again. So this also allows you to know that there's some sensors that are also into the gastric region, so verifying correct position is very important for acquiring a high quality test. Um, there's different text. Things you can do. Depressed is the primary one. You can have them perform a test wall and again follow that swallowed down and u C L A s when it's a resting. Opening relaxes. It goes back and you see there's enough. Some sensors down here are key is we're gonna try to target at least three sensors in the gastric region. Always try to stay at least two sensors in the fair NGO Reason region. But this can change by the length of the Soph ical body. Um, all kinds of different things and different anatomies. Just the other day, for example, I was blessed to dio soft Julian. I'm sure with my teammates, and we actually did in someone that was 68 I believe, 6869 As you imagine, his esophagus was super long. So in general to in the fair fairness region three in the gastric region eyes our target. You see the line Well, this is why it is basically indicating the beginning of the small to the end of the small. When they take that big, deep breath in as you see they inspired take a big, deep breath in the Jurassic Region will go low, Remember, On the pressure color region is similar to a weather region that red indicates high pressure blew even low blue degree indicates low pressure, low pressure No matter what the scale you put it on. If you put the scale of 0 to 1 50 red will be around 1 50 0 will be blue. If you change the scale from 0 to 2020 will be read and zero will be blue. So it doesn't matter what the range is. Just two colors will stay the same. But deep breath in you see, the drastic pressure goes down. You see, down here the Gasser pressure goes up. This verifies that the catheter has traversed beyond El Es into the gastric region. This is verifying that you have good half the replacement. It's really important placing the catheter correctly and accurately and verifying that you know this place correctly and accurately because proper catheter placement allows you to get a numerous number of baselines that will be referenced as basically baseline zero pressure for the rest of the pressure swallows as you move through the study. So these are the gastric baseline south of geo baseline fare, NGO baseline LDS and south of your body and fairing. So these are all very important to when your place getting the catheter placed correctly an actor and as you see mathematically thes bars right here represent these baseline and you see, you always want them in a very quiet or quieter area. So in the fair, in jail area, these blue areas and you can move these and we'll see this more on 11 are three and four webinar three and four that you want to get these in the proper region so far in jail. Asafa Geo body in gas. Strict again. The target remembers these three centers in the gastric region. Any questions before we move on to, you know, some pearls wisdom for partnership between Allied Health professional and the patient Jason. There is one question. Does the patient's hand position impact verifying? Cap it replacement? It's a good question. So this is probably done, Um, quite a lot, because the patients, even if you think about when you go to the doctors or so you most a lot of patients and literature has shown that patients will put their hands together like this. It's almost like a comfort typing, and they'll place it on their belly most of time on their top part of belly and also just trying to stay calm almost like a sleeping position. But if you if you put if you do that, you put pressure on the top part of your stomach that can induce greater pressure around that catheter placement. Mostly Elias region artificially just by the little bit of pressure you're putting on that upper stomach area. So we always recommend hands down by the side. We can give them towels or four by fours, and you could squeeze them like squeezy balls, type of things, Trent tension balls, but you wanna keep their hands down by the side off their abdominal cavity. Good question. All right, um, what's the best local anesthetic to use? Uh, one of their facilities uses viscous lidocaine. Is hurricane spray acceptable? So, for a long time ago, for many, many years, by a decade, from 2000 to 2010, we used hurricane spring. Um, we went away from hurricane spray, Um, for many, for many reasons, the way that we're applying it through a straw type of thing. And we were basically coating the whole mouth. And patients had some just dislike to that. And also way had a pulmonary lab nearby. That was another way. Get a lot of pulmonary pre lung transplant. So there was a reason we went away from the hurricane. I would say most places around the country used 4%. Viscous lidocaine is the anesthetic of choice. Um, but I think that's a good question to take back to your home face and find out what you have available. That type of thing. But that's the reasons we went towards viscous lidocaine. More patient comfort than anything. Okay, um, any tips for increasing innovation when patients are anxious? Oh, yes. We're going to get to that great question. Great question. and before we before. I'll answer that as we go through the next one. And maybe if I missed something, we can go back to that question at the end. Um, but I do wanna make ideo I say this quite a bit when I get them blessed to be able to teach people around the country. This is that, um you have to think about this is a non really a non sedated procedure. It's, you know, it's a little scary. Um, in the sense of someone's just meet for the first time, they're standing basically six inches from you. You're being trans natively, intubated, more than likely for the first time. Um, there's gonna be some anxious nous, you know what I mean? Like, I, uh that so I don't think everybody is high anxiety, but I think you have Thio. You have tow go in with the mindset. There is gonna be a little bit of anxiousness. Andi, that's it's gonna be part for the course. So I always try to tell people that not not everybody has high anxiety. It's just anxious. Nous is just gonna come part off this procedure. I mean, um, what position are you performing the study into pine 45 degrees upright. Good question. We're gonna talk a lot more about that and webinar to next week. But, um, if you're gonna apply the Chicago classification, the 10 analyze herbal swallows have to be is should be done in the supine position because that's what the classification was created on. So we do supine. They've gotta be very careful. If you don't use a pillow or a little bit of a towel, you can get someone in trend Limberg position just by the gurney or the chair there on so And that will also not so much impact the Chicago classifications to use your swallows. But it really will impact them taking double Sewall's, because now it's basically there's this gravity pulling it back down, so you gotta be sure. Make sure you use a little bit of a thin pillow or a towel of some nature, but before you put them in a supine position, it's really important to ask about back surgeries, hip surgeries, that type of thing. So sometimes people may not be able to go all the way back to 100 close to 180 degrees. You may have to play with that a little bit to get them into the supine positions. Closest possible for their comfort. Okay, um, what does it mean? If the fair NGO baseline is not there, it's not going to impact it so much. I would say the gastric, the gastric baseline is by far more important than the fair in jail based, unless you're looking for, um, like your, uh, ear, nose and throat type of issues. Then you could you what? What you could do is you could do, um 10. Analyze will swallows in the supine position, apply the Chicago classifications, and then you can pull the catheter as you're coming back out to about 35 40 centimeters. Then you'll have a clear image of the fair NGO area and do like five or so swallows in that region. And then basically, you won't see the l es. But now you're basically just evaluating the fair NGO reason region. We do that quite a bit on different types of patient cracking fair in jail. Just Asia is one big diagnosis we do that on, but it's a good question. But if you want oh, bypass one. Do you want? The gastric? One is more a little bit more important than the fair NGO. Basically. Okay, we have a few more questions, but I think we should move forward, and we Can I enter these events? All right. Sounds good. So I'm a big believer in partnership. Um, 20 years of doing this, um, I this is this is the most important thing that I teach. Um, even when I'm teaching new people and new staff how to do this, I believe in Partnership Partnership Partnership. And this is something I, um I means a lot to me. So I think as we go through this, I think there's some techniques that I've learned over the years. I hope to share with you. Um, help you get to patients through these thieves. Test. So again, this explaining the procedure. You wanna be engaged Often. You noticed newer people starting. Though there's no concentrated on the computer. They lose the engagement with the patients, so you need to stay engaged. I almost call often. Um, the partners. I'm blessed toe partner within this is that I always say I would say that you're like a Manama tree coach Or if you ever had, like, a fitness trainer, this you're basically that for them in the world of Manama trees. So engagement, engagement, engagement, encouragement, encouragement, encouragement leads to empowerment, empowerment, empowerment. So reassurance that doesn't If they, you know, it may take you 30 40 swallows to get 10. Analyze herbal swallows. That's okay. You want to make sure the insurance is no problem. You know, you wanna make sure they stay in a positive line, sight and mind site. There's gonna be gagging. There's gonna be repeated swallows. There's gonna be belching. You could do relaxation exercises. You can. You can play music of choice. I I often say you could we could play music of choice. I just asked her to be a non cussing music. But any music is fine. Whatever helps them out. Um, some places have TVs and they could watch anything. Any cable station they want any of that type of stuff allows, you know, allows them to calm down. There's techniques of opening the mouth. There's almost like a biofeedback thing. You can move the chair bed closer so they can kind of see on the corner of their eyes of the clouds plot, so you don't want to swallow until he just waits 30 seconds. You can almost take a biofeedback type of thing. They could squeeze on attention. Balls concentrate a focal point. Sometimes people have those pictures where you look in there and try to find a certain image. All of these types of things, they're techniques that can help the patient get through through the test. But some pearls, always I've learned over the years I hope to pass along is that you would allow time for the patient to express themselves so often you notice that come into the lab or physiology room. And, you know, they unload a lot of their lot of a lot of feelings they have about their trouble swallowing or reflex or this global sensation or south of chest pain. Chest pressure you want you want to be an active listener? Sit down the clipboard. Don't be looking at the screen. Often. I even go over and I turned. I turned them screen off where that shows how the how is the patient s so that I am not concentrated, anything else besides he or she at that moment? Um, you want to be an active listener? Active listener. So then there's a thing called the talkback methods. So in research, this is very important. But I also apply it to Manama trees basically, as after you briefly explain the test to them again around eighth grade reading level in the United States. Because that's the health literacy level is that you want them to explain it back to you. They don't need to be word for word, But long as they kind of understand the gist that now you guys were communicating and in concordance instead of discordance, you don't ever tell them I'm a big believer. Don't tell the patient that. Relax, because often and more do you tell them. Just relax. Just relax. Just relax. That in itself makes them a little bit more tense. So you wanna make you wanna maintain demonstrate productive strategies without saying, uh, you just relax? Just relax. Um, you want to prepare yourself for the possible situations of the study. So as reading during that pre procedural homework, you'll have somewhat of an idea of a little bit about the patients. But your body language will stato the more frustrated your again. You don't even have to verbally say it. Your body language will say it. The sides will say it. You wanna practice really positive body language? The patient will feed off you even though they know they're having challenges by double swallowing, gagging all that type of stuff. And you wanna be empathetic. If you've had the study done, you can. You can really talk to them from a patient patient, the patient type thing. But you want to be empathetic to them during through working through discussed. So in summary, basically, the esophagus is a tube to transfer matter from the mouth to the stomach. Um, there's a lot of physiology and anatomy that goes along with that. But as a south of geometry, this sophisticated catheter and sophisticated software really allows us to tease out what may be working, um, accurately, what might be not working so so well. So this is a very sophisticated software and catheter software provides this platform to strategically organized your soft NGO Manama tree test. If you're from a tertiary care center or research center, these tags are very important, especially when you're starting to find tests to prepare manuscript or prepare for an abstract for a meeting or just teaching fellows or visiting professors or new staff members. So take advantage of that. I believe accurate placement of high resolution soft human on a tree is pivotal for getting high quality test. So understanding when you know the catheters placed correctly and incorrectly and learn different techniques to it, make real time adjustments. Um, to get that Catholic replaced correctly. The partnership impacts test results and also patient satisfaction. The patient compliance. So, um, really important to develop partnership techniques? Um, help partner with the patient that work them through the test and become a Manama tree coach and just not a clinical staff member? I really appreciated by listening to webinar one. I take any questions. Um, for the remainder of the time, we hope this entices you to come back to Webinar two and three and four. But this that really sets the stage the fundamental stage as we work through the next few webinars. I appreciated bodies time on a weekday night. Thank you. All right. We have ah number of questions in extremely anxious patients. Does one dose of alprazolam or Dad Pam acceptable or will it negate results. Good question impacting results. My my experience is no, um, doesn't really impact the results too much, but you wanna be able to give that dose sometime time frame before they arrived for the procedure. If you give the dose, um, like, as they're sitting in your chair, it's probably not going to impact their anxiousness that also, um, in the past. What we would do is we give that, have the physician order it, they would ingest it about two hours before the procedure procedure time they get the highest efficacy of the drug, so you it won't impact your results. But you want to do you definitely want to get the right timing according to the half life of that drug, get the highest efficacy for the patient and get you through that test. Also in a pediatric patient. How do you get a good baseline pressure if the patient will stop swallowing? Good question. So I was blessed to work for with pediatrics for about 19 years, along with adults. Um, you know the thing, the tool that helps out the most two things I think you need to read the parent or the guardian because just your your body language, they'll feed off that. But the really feed off the parent, parents or guardian or guardians in the room. So, um, our practice, what we did is really allowed one parents or guardian in the room and way had a little bit of a conversation with a parent or guardian before the test. Is that the understanding that you know the child will basically feed off your body language? So if we can all have positive body language is and the other thing is that it takes them a little bit of time to get used to it. But we purchased an iPad and we downloaded or streamed like many Disney movies, our YouTube and we basically they could be on the iPad or YouTube, and then we work through to study that way. That was very productive, that $500 investment was very productive for pediatrics. But body language is really important that you and the parent or guardian on that that applies to all type of Manama. Jeez, it's not a south of you. Is there a patient population that Manama tree should not be performed on? Absolutely. That's a Good question. Um, I don't know if it's so much a patient population, but patients that, you know that have, um, on Assad programs may be huge. Particular homes are really tight structuring, Um, some type of anatomy type of thing like that, Um may lead you. Not that soft German entry may not be the best test for them. The hand to evaluate your decision s. I don't think it's a patient population. More of the anatomy type of issue may lead you to decide to do another test over in the South of geometry. That's a good question. That's a good question. But I think that would be a really good approach to that. Are there any special measurements for a pediatric patient? No. Um, the Chicago was done with adults, but often in the literature, Chicago is used for pediatric measurements also, but the measurements in Chicago were based on adults. So all the same metrics that we're gonna talk about webinar to and beyond, like the AARP and the D. C. I. Deceleration point basil pressure of the upper south of Jill sphincter lower south of jail. Sphincter late. See time fragments. All that type of stuff. You will be applied to pediatrics. But knowing that Chicago was based adult and pediatric, so you would probably have to use those measurements. Um um Mawr by your expertise, um, in pediatric care in relation to their reason why their happiness off. Gentleman amateur. If you have double swallows at the time of the procedure during the procedure, the Manama tree studies still accurate. Yeah, if you you're gonna get double swallows, that happens frequently. Um, you just don't want to know that you're not gonna be able to analyze that swallows. So that does not count within the 10. Analyze Bill Swallows. So you need to continue to acquire enough swallows where you get 10 good ones. But remember when they double swallow the 3rd 30 seconds phase before they can have another ingestion of of Ebola's happened starts after the second US break. So, um, knowing these time frames, um, is important and will work throughout the webinar three and four, But you just won't be able to analyze. That's well that that's what I have to be deleted on. You just need to continue to work until you get 10. Analyze Herbal Sewall's. There's some techniques toe stop double swallowing. You know, sometimes you can You can press your tongue on top of your palate. You can have them kind of chew out of straw, especially, um, going back talking about double Sewall's going back to a previous question. Probably my experience. The most challenging patient population to do in the South. Gentleman amateur on our people who have clinical chronic hiccups because they're they're constantly breaking the US, So techniques of having them chew on a straw in between swallows, they bite their teeth around it, press their tongue really tough against their palate. Can can hold on just a long enough. It seems to before you keep the US without breaking. Um, So there's some techniques to that from refrain from having double swallows. How do you handle a patient upon Coumadin? I'm sorry. Uncommitted? Yes. Um, uncommitted as don't want really want to go through the test? I'm assuming that I'm sorry on Coumadin. Oh, I'm Cuban. It Yeah, that's a great question. That is a really good question. I would say that that varies from institution to institution. Um, depending if you have, like, there's institutions that have, um, Coumadin team of nurses that basically evaluate all endoscopy procedures. Uh, people who are on coming in so they monogamous gets kind of gets thrown in there. Um, we perform Manama Tree on Coumadin. I think the risk is sent to be very low, but that is probably for an institution decision, and that varies from laboratory to laboratory. But really good question. That is a really good question. I think everybody listening probably should have the conversation with their institution that you come up with a game plan and most of time that follows. Ah, very similar plan to endoscopy. How long after a brawl study can a motility need performed? Good question. I we've done so that larger centers, especially tertiary centers way have done. If we have we replaced the Bravo, then we could You could actually place the Manama tree counter at the same time. That's probably most places since bravos are. While those PH capsules are are either 2 to 4 days long. So generally probably a good rules, uh, good rule would probably do at least five days after that would give you the greatest likely that the Ph capsule has been slough it off and is making its way through the G track. Um, that's probably more of the common way. Doing have a big tertiary centers. You'll see them doing Bravo and Manama Tree on the same day, mostly just to help patients because they've traveled from a long distance. It's more patient compliance than anything like that. But you gotta be very careful when you're removing the catheter, not the not the the capsule off. And you know that by looking at the pH before you started testing the pH after here by removing the Catholic very, very slowly. Alright, if the size of the U. S. Changes with swallows should we adjust the US parameters, we'll keep it at the original resting box parameters. Yeah, I was eating. That's an interesting question. There's a lot of research being done with us right now from several universities in the United States that I know of and probably come around the world. Also, um, you should maintain the maintain the region of the U. S. Of placing the measurement boxes to that and not worry so much about the diameter of the opening closing. Um, but the big thing is, get the US high pressure generally in the middle. That US band that gives you the generally the high pressure zone of the U. S. And allows you to know what the relaxation is when the bullet goes through there. That's an interesting question. I think I think that will probably be teased out as the years go on. All right, Jason, we have 10 for one more question. Um, is there a problem performing high resolution of soft the Geo Manama tree and patients with cardiac pacemakers? Manama Tree. No, we've done quite a bit of those. There's no magnet and no battery, you know, lithium and that type of thing. So, um so for for Manama Tree? No, but, um, as we get to webinar three and four, there is some You gotta be aware of some pressure and especially the south of your body. And we kind of let you know, this may be more cardiac, but from a meta metric standpoint, there should be no contraindications. Um, for performing Manama tree on people pacemakers. Great. Well, thank you, Jason. This concludes our webinar anatomy procedure set up and proper probe placement for high resolution esophageal Manama tree. Please join us on September 8 from 4 to 5 p.m. Central time for the next revenue in the Siri's, where we cover test protocol, Chicago classifications and editing stops. Thank you and good night. Created by
