Chapters Transcript Video High Resolution Esophageal Manometry – Start to Finish Webinar Series (2/4) Review of test protocol, proper probe placement, Chicago Classification 3.0 and the steps to edit a normal study. Yeah, until mhm Hello and welcome. I'm John L. Schmid, the marketing director here, a diversity of health care, and I will be your host today. Diversity Healthcare. Excited to present our webinar Siri's high resolution esophageal Manama tree from start to finish. Today's topic is test protocol, Chicago classification and editing stops. I'd like to introduce our speaker for the 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 at national and international annual scientific meetings and very recently was elected as a council member for the American Narrow Gastroenterology and Motility Society. A few quick things before we begin, the webinar is being recorded and will be uploaded to diversity at university. After the Siri's have ended, your microphones have immediate for the duration of the webinar. If you have any questions, please send them at any time. The the questions box under go to Webinar panel, and we'll answer them during the question and answer session. At the end, we'll do our best to answer all your questions, and for those individuals that do not get their questions addressed, we will respond to your question. Once the webinar is over, I will now turn it over to Jason. Well, thank you, Juno. And thank you for everybody is joining for, uh, Webinar two of our four steps. Siri's You know, the first one is we basically looked at the anatomy and physiology relative to swallowing and from the south of Geo Manama tree standpoint. So we're gonna build off Webinar one and webinar to here and again. We're gonna look at a standard protocol. We're gonna show some other type of provocative walls and we're gonna talk about the difference of the protocols. We're gonna look at the Chicago classifications, and we're gonna show a editing steps of editing. Asafa Geo Manama Tree Preparing us for webinar three when we actually will edit a normal study. So some objectives for this webinar we're gonna get review. Uh, standard protocol for high resolution ISAF Geo Manama tree. We're gonna review the Chicago classifications version three. That's the most updated one. Then we're going to describe the steps for editing a Manama tree study and of sequence of when you're our actually going to review a normal study. So the standard protocol, there's a lot of protocols out. There is a lot of different provocative swallows that different labs use when they're doing a soft geo Manama tree, and they're all listed right here. But the one that these are what's highlighted in purple is what is necessary to collect to employ the Chicago classifications. So when after you as we showed just that, Webinar won the art of placing a catheter after we get the catheter properly placed, verifying that by deep some deep breaths, looking at where the Paracelsus ends by giving them a couple practice swallows and making sure that we have at least three centimeters in the gastric region and two centimeters in the fair. Geo reason. We want to give about a five minute acclamation period. This is very important. The first four minutes they can swallow a much as they like. They can kind of get used to the catheter, having that place what the feeling is, but also it's allowing the body to acclimate. Thio catheter the body, the catheter to acclimate to the body's temperature on. That's gonna be important because we had a temperature of the catheter outside the body temperature. Now inside the body and as we pulled out the temperature again outside the body, and then we'll have to do some thermal compositions. And as we walked through the steps for editing, well, describe more of that. But after the five minute acclamation period is basically where now you want to take control of how, how and when they swallow. So coaching them through that remember partnership being a partner during this instead of a nice, elated silo in the room. But definitely partnering with the patient is very important. You want to have them take five depressed again. The intra drastic pressure will go decrease in gastric pressure will increase. This is verifying the Catholic replacement, then right after that that they're withholding from swallowing. You want to collect that 32nd landmark baseline, which will be very important. Um, no swallowing in between there. You want them to breathe normally, you don't want them hyperventilate. Our brief quickly. Just normal breathing. You want to coach them through it basically, every five seconds. Tell them where they're at. Give them encouragement. Let's say, for example, they swallow during this baseline period. You could you could start it again after, you know the 30 seconds from the last Swallow and but say you do two or three times, you may want to move forward with the swallows and try to collect the baseline after or during after you bring them back up from the supine Sewall's. You can collect at any time during the test, but knowing there is some variability, it could occur in the upper south of Geo on the lower south of Geo Basil pressures, but you can collect it at any time. Then you're gonna put them down in the supine position. You want to do five depressed when you're supine position, making sure you don't have to do any adjustment to the Catherine, and then that's where you want to collect. 10 five ml of sailing What swallows in this position So you want to try to collect 10. Analyze herbal swallows each other Small box will be about 30 seconds, 30 seconds in length, but or inter until the L. E s pressure returns to the baseline pressure. This is probably more important than just waiting 30 seconds. Recognizing that the baseline pressure before this wall is now the baseline pressure before you give another small There are some provocative swallows, um, that are all important for adjudicating from Eckel Asia subtypes to outlet obstructions and of that nature. And these are operate swallows multiple rapid swallows. There's a fast swallows or a large volume swallow. There's a cookie swallow all the way to a meal swallow. But for Chicago, you need to at least collect these right here to employ this portion to employ the Chicago classifications. So there's a technique for acquiring a analyze will swallow again. You want to use five MLS of sailing per swallow. You wanna try Thio. Employ this trying to do too much or too little, especially to little. You may not get the same amount of vigor during to swallow, um, especially in the supine position. So it's really important to try to get five MLS. The best way I do this is I use a 10 ml syringe, so basically, when I employed it, half the syringe goes in there. So if you use a bigger syringe, sometimes it's harder to see the little five points on the syringe itself. You always want to start the measurement area first before you give the swallow. If you don't you can adjust it during the editing phase, but it's a good good practice to do the same rigorously throughout. Start to start the measurement window employees this five ml saline, then have them swallow once and only once, and coach them through that, um, coach them through that until the 30 seconds is, um over or until the baseline of the less pressure returns to what it was before the original swallow. And then it just generally takes about 20 to 30 seconds. And this allows for complete bullets transit if it's gonna occur and also avoids the glut of inhibition. Basically, this allows for another contraction Thio manifest during the same swallow window. So here's the Here's a depiction from the Manama tree standpoint as we started this wall, the measurement window and then, as you see the U. S. Is now broken. That means now we employ, delivered to swallow at five miles into their mouth, again delivered to their cheek outside cheek. Let them delivered to the back of their mouth instead of having a syringe deep in their mouth, because that could cause them the double swallow or gag. Then a swallow comes down and you see in this purple box that kind of represents the sailing going down because it has a lower amount of impedance and over air. Then as it comes straight down and then you see it goes into the stomach, This is right here what their baseline pressure was before to swallow. So even though the 30 seconds ends right here, you also want to keep your eye out looking, What this pressure is before you give another small, for example, it is all in this red color Still kind of come right migrating through the tracing. You wanna wait until the baseline pressure comes back to what it was previous? Thio the original swallow. So liquid swallows. You know, it's important for bullets transit. It allows us to do different measurements in the Paracels wave. Then, although both bola transits and the wave measurements are measure simultaneously in high resolution Manama tree and again it's very important to get 10 analyze herbal swallows with sales If you use another product besides sailing, you just want to know the salt content may not be at the optimal level. So you wanna be I really encourage you to use sailing to give these swallow so impedance data is collected also during high resolution esophageal Manama tree We really use sailing because in previous studies that were looked at sailing, it was measured in very, very low. Holmes and Holmes is what we measure resistance, it and impedance. And that's the reason that we want to measure you sailing. If you use another product, you may not be ableto pick up across all the channels to actually accurately measure and assess bullets transit. So we're going to start looking at some high resolution Asafa Geo economic terminology before we move into the Chicago uh, really walking our way through the Chicago algorithm thes air key terminology you're gonna hear, especially as you assess each individual swallow, but also within the Chicago classification itself. The first one is probably probably the most recognizable. One is called the IRP Integrative relaxation pressure. Mm H g just means millimeters of mercury. And basically I r P is the mean e g j pressure within the electronic sleeve. And we'll show that as we get through some minima trick, uh, depictions, but it Z within this 12th box. So the mean lowest, mean pressures measured by four continuous or not continuous seconds within this 12th window. And as you see in this minimum minima trick illustration here is that here's the swallow comes down. Remember the U. S Open that originally initiates the swallow About two seconds after the U. S. Opens, the L. A s will start to relax. And then within this 12th box right here, it's kind of circled in this big white oval thing. There's every second the software's calculating pressure, and it's going to take for the four lowest pressures, continuous or non continuous on give you the mean for each of these swallows. But as you as you work your way through this, you're gonna have 10. Analyze will swallows, and it takes the median. What you see on the report eventually is the median of the 10 mean higher piece measurements in each individual swallow. The next one is D. C I, which is distill contract out integral so again, Millimeters of mercury times duration times length, and this is of the distal esophageal contraction um, greater than 20 millimeters of mercury pressure from the top part of the smooth muscle down to the distal part of the pressure trump. And this is basically the vigor of this wall. So as it bypasses the stride and muscle bypasses transition zone, you get to this trough right here the smooth muscles trough. You got the proximal portion. You got the distal portion here on this oval, you see the same thing, the proximal in the distal. So this is basically taking a measurement of millimeters of mercury pressure greater than 20 times the length and times the duration. And it gives you this calculation of a number of a value of how strong, weak or absent. This maybe the next one is the contract out deceleration point. This is basically a point in time in the position. So it's the inflection point along now, the 30 millimeter Mercury ice bar, contrary where the propagation velocity starts to slow and that the markets where the swallow phase as ended, and now the empty and phase into the stomach as beginning and again here as the swallow opens, that's gonna kinda just swallow. The Paracelsus wave is following um, following the bullets down and as you get to this point right here, sometimes called the elbow down here. But this is This is basically the point where the deceleration point is where toe swallow as starting the end, then the empty and phases starting to begin. Um, the software will put really good algorithms putting this in the accurate place. But sometimes you do will have to adjust depending how Well, how long to swallow is I'll short to swallow is but it's generally located somewhere about two centimeters north of approximately s border. Is this an eye point where this is generally located, Then the next one is dlr, Just a leighton see? And this is basically the interval of time between when the US relax and to this deceleration point. So the deceleration point pays plays a couple of different things. It allows us to measure how fast to swallow is so soon as the US breaks, it starts to open. This will measurement of time will come down to just deceleration point, and this will allow us to see how fast how slow the swallow is. The next one is we're gonna be looking at Paracel para self breaks, and this are gaps within that 20 millimeter mercury bar of contractions between the U. S. And E G Jr, um, portion of the swallow. So as someone swallows, we're gonna be looking for breaks in here greater than five centimeters. So, um, these anchor bar's show you that this is a normal swallow. This has a transition zone gently less than five centimeters, and this is what this is impacting. But as we look at the next one, this large gap between the strategy muscle and where the trough actually begins is greater than five centimeters. So we're gonna want to keep our eye on this length right here on BN inside the software if it's missing or you can actually want to measure it. There's ways to put these Anchor Bar's in here for the software let you know exactly how long this break iss. So before we move on to reviewing the Chicago classification, is there any questions that we may address from the first couple sections of webinar to? Yes, Um, we have a question regarding water. Uh, can you clarify the use of sterile on distal distilled water and when you would add saline, are you also having the patient drink the sterile distilled water with saline? It is okay to give normal water in place of saline per swallow. It's a great question. So are the practice that we've employed for two decades is that we use sterile water or distilled water when we're placing the catheter. And then when we want to start having the five ml swallows in the supine position or any of the other provocative swallows, we we do that with sailing This will we know basically, when we ingested when they ingested the basically the research variable the intervention variable sailing into the high resolution Safi Geo Manama tree program Going back Thio, can you use regular water? You know, tap water has a lot of different ions in it, so it's gonna be a little bit challenging to know when you actually gave them that type of unit to measure impedance, so I probably would stay away from that. But can you use it? You could use it, but maybe a little bit more challenging to measure impedance if not a big challenging. You even use that type of analysis. Um, what about using discuss? Yeah, we do viscous swallows, but it's it's more part of the provocative stage of the Manama tree. So after we collect the 10 analyze well swallows with five ml of sailing because that's what the Chicago classic ation calls for. The employees that index we use viscous swallows, form or adjudication take things, especially to outlet obstruction and that type of nature. But we do that during the provocative swallow, not during the 10 analyzed, and we do not include those during the 10 Analyze herbal Swallows. Can you drink Gatorade and see impedance with that? Yeah, Gatorade is used at some places. Um, I would just say Gatorade doesn't have. Can have. Does not have Ah, probably the proper amount of sailing inside Gatorade. So if you were gonna use Gatorade, you probably wanna add salt to that drink and and, you know, and stirred around the ad sailing to Gatorade tends to be leased a marketable ones that you buy in a store doesn't have enough sailing to sometimes pick up very low homes. Alright, regarding the five minute adjustment period, if you're not performing that currently, how does it affect, um, thermal compensation and diagnosis and so forth? Yeah, generally thermal compensation. It won't impact too long unless you're doing a protocol called rumination protocol. Because generally in a soft, soft geo Manama trees done within about 20 minutes or so, and if you do a rumination protocol, it's something could be up to two hours, so the drift will be long will be greater the longer the study is. But if you're not, you're in acclamation period beforehand. Um, some of the pressure right when you put the catheter in with not having an adjustment period could be greater than after the adjustment period. So if what I would challenge you to do is when you go back to your lab, do somewhere the the adjustment period for five minutes. You'll see, especially the basil pressures will generally be slightly, uh, lower than if you just start right away, because the patient's kind of getting used to it. And the second point is that adjustment period allows the patient to get used to having the catheter in their body, and they can generally get through swallows much quicker without eliminating double swallows or gagging. Um, that type of nature so may be to your benefit. They also do the adjustment period. Besides, um, those two of the other two points all right, before we move on. We have one last question regarding position. Actually, a few of them, um, is supine position a must or can you do it in a sitting position? And what if that person cannot tolerate being flat? How important is it to be in a supine position? Both really good questions, both really good questions and get this question calm. Very commonly. Uh, it's just it's the first point. Chicago was done in the supine position, so in theory should try to get as close to the supine position. But you want to be very careful when you lay their head back to use a pillow or very thin are very thin pillow or a towel because you don't wanna put them in trend Limburg position that would just allow them. They'll gag more often it that way. Um, so you want to try to get them in the supine position if it all possible. But we always ask, in the labs that I've been in, we always ask, Have they had back surgery or the undergoing a lot of back pain or hip surgery, especially hip, uh, replacements? If that's the case, um, you want to bring them back until where they're feel comfortable with. But you definitely want to know Tate on the report that it was done in a 45 degree angle, or some aren't all the way in the upright position. But people, sometimes with actual Asia, are outlet obstruction. When you do have them in the supine position, it's not uncommon to have them bring them back up and let them clear their throat or vomit, because the content you're giving them are not bypassing into the stomach. So you may have to bring them up a few times and let them clear their throat, then put them back down in the supine position. And the last thing I want to say about the supine position just for ergonomics and staff safety. Um, if you have a gurney that's not remote control, remember, you want to get behind a gurney and push them up that way instead of pulling them because you could cause back injuries that way, Um, or invest in a remote control type of stretcher chair. Um, definitely for economical purposes. All right, so let's move on to the reviewing of the Chicago Classification version three panel. So you get this this algorithm a box right here. And it kind of walks you straight through, um, each individual type of swallow what you need to be looking for all the terminology that we just kind of reviewed in the previous few slides. So it breaks it down to a here archeo analysis. It looks for disorders with E J each of J outflow obstruction that could be outflow, obstruction, oracle, Asia. Then it breaks it down to major disorders. A pair of Stahl ASUs. And this is this esophageal spasm jackhammer, esophagus absent contract Il ity minor disorders of Paracelsus Ineffective esophageal motility or fragmented be honestly. And most of the studies that we see are I am s Oh, don't be Don't be concerned. If you see a lot of I am as the final report, um, that and there's normal studies. But as you look at normal studies by RPI is normal. But 50% of our effective swallows that means 50%. Maybe ineffective swallows still would be normal. So we're gonna walk through this each one of these sections point by point to kind of show you a few sewall's and what to look for when you're reviewing each individual swallow. So from Webinar one, we talked about this E g j morphology type 12 and three. And the importance of that remember type one is basically we're both the diaphragm. The l. A s almost right on top of each other. You don't see any separation. You know the pressure inversion point and the high pressure zone. And within, like usually half a centimeter from each other. Um, type two. There's a little bit of a separation, and this is where we're gonna start. Kind of characterizing these hernias a little bit of a separation. The pressure version point is a little bit lower. Member of pressure version point tends to be right around the diaphragm. Then you've got type three, and this is separated by three A and three B and only thing differences. The protective barrier from the diaphragm in 38 the the barrier. The diaphragm tends to be consistent and a little bit of protection from having stuff moved from your stomach into your esophagus and then and then three b is basically that There's big gaps in there also, and you really don't have even the last line of defense from having stuff emanate from your stomach into your esophagus. Now, as you see it now, Metta Metric Lee here, this is type one basically again the diaphragm. Delhi s basically right on top of each other. You don't see any separation here at all. Compared to type two, you can kind of see this little separation. These blocks of pressure right here represent the diaphragm as their inspiring expiring. And then the l es pressures up here. Then when you get to type three, you got the L es. Here, you've got the DIA France significantly lower. Then you can kind of see this This green pressure in between the diaphragm diplomatic pinch, there's still a little bit of a barrier. But if there is nothing of green or no representing a certain pressure, remember, red means high pressure. Blue means low pressure. Green and yellow are kind of in the middle. If there was no barrier here, this would be end up being three b. But I would just kind of recognize type 12 and three. This is where you represent kind of demarcate a hernia being present during a stop a geo manama tree. So we're gonna look at disorders first disorders with GJ outflow obstruction again Eckel Asia Outflow, Obstruction and the criteria for these are represented on the left hand side here. So in Eckel Asia, all I R P is greater than 15 millimeters of mercury pressure. IRP demarcation line is 15, um are lower is normal. 15 or higher is abnormal. Um, if when employing the Chicago classification there's 100% of no pair of sauces or spasm during this this type of disorder of actual Asia, then outflow Obstruction is where you have abnormal I r p. They're greater than upper limit of normal. And but now you do have Paracelsus greater than 4.5 centimeters per second. That's the normal demarcation line of a normal Paracelsus waving a swallow on a single swallow and actual Asia. It's less than 4.5 centimeters per second. So here, as we've seen meta metric Lee Eckel Asia type one as you see the l E s U S is broke up. When you gave the five ml swallows the L E s, there's no relaxation at all. Remember, red is high pressure. Blue is low pressure. There's no relaxation at all, and it's absent of any Paracelsus at all. Type two in the middle here is basically got the U. S. Opens with five ml swallow and then you got this pan esophageal contraction you often as swallows go on, you'll see the you see another contraction, another panel contraction. Other panel always straight down, and they'll get more rampant at the As time goes on. Often you don't have to bring them back up to clear your throat. Then some of this will go away a little bit. But as you get mawr, swallows and more five MLS and swallow, you may have to bring them up again because you'll start to see multiple. These simultaneous contractions started occur again. The I. R P does not relax at all you know is greater than 15 because you actually see red in this in this brand right here, but no relaxation at all. Type three again. You've got the U. S. Opens Dire P doesn't relax, and the two just deceleration point from this point here is less than 4 4.5 centimeters per second. So it's it's very is quicker than a normal swallow, so this would be categorized as type three. Often this d c. I is very large. Eso don't be concerned if you see a lot of red in this even to deep pink outflow obstruction When you when you start to learn more about these things and see more of these swallows outlet outflow, obstruction, type three kind of have to have. There's one little key point is that this is greater than 4.5 centimeters per second to swallow from when U. S opens to the deceleration point down here in the member, that's the distal agency. And as and right here as you see, the the uh L E s is not relaxing at all either, so it's greater than 15. So the difference between type three and outflow obstruction is Paracelsus. So here's to give you a little, uh, basically what we just said here it gives you kind of look a little bit of a cheat sheet and what I often do, especially when I get new staff, is I we make little cards or these and we have them for the staff member when they're starting to learn Manama tree. We have all staff member, um, kind of go through each. We haven't go through each swallow, but also try to score it itself before you hit the report. See your eyeballs and you're more and more your knowledge. You're starting to click together and eso these are just basically what we just talked about throughout the last couple of slides. Previous is but take three. Just want to point out one more three. But take three smiles that off this metrics I hear greater than 20% of these have to be in this range for this to be actual Asia. Type three. The next thing we're gonna look at his major disorders of Paracelsus and this again is distal esophageal spasm, jackhammer, esophagus and absolute contract. Hildy So distal esophageal spasm is where there is greater than 20% are of the swallows or premature again. That means less than 4.5 centimeters per sections for the dis Elaine C. That's again point the point where the U. S. Opens to the deceleration point. Then you got jackhammer esophagus. There were greater than 20% or two of 10. If you're collecting 10, swallows are greater than 80 88,000, then absent contract. Il ity is basically where there is no contractions at all, and you may have to consider that Malaysia, but often the i. R. P and these these swallows are normal. All right, that's basically what we just described in that last swale. So here's absent Paracelsus from the sense of a Manama tree as you see the U S. Open's and then there's no Paracelsus at all. But now compared Thio converse to the ankle Asia ones you get relaxation of the L. E s and I. R P is normal so lower than 15 millimeters murkier pressure So but often these air another folks, you'll have to tend to bring them up every three or four swallows and let them clear their throat. Distal esophageal spasm. As you see the l E S U S opens. Sometimes this is hyper contract out, but it open. But instead of having Paracelsus, it's almost it's premature. Less than 4.5 centimeters per second and I r p for relaxation is lower than 15 millimeters mercury pressure. So two of 10 or 20% of the swallows if you get less than 10, analyze herbal swallows have to meet this criteria to be just little esophageal spasm. But here, as we were talking about before, so to say this is the beginning of a swallow window, as in swallow liquid number six. As you see this L E s. If you look at here here. If you think if this is a light yellow and then to swallow say, this is the end of the 32nd window, for example you see, the L E. S is still hyper contract out. You need to wait until this El es comes back to the pre swallow el es pressure before you give another swallow. So sometimes it's 30 seconds, but it can be greater than 30 seconds. Just do, depending on what the L. E s reaction is to the swallow itself. Jackhammer, esophagus, A couple of things here that remember this is a D. C. I just still contract. I'll integral is basically this contraction of this vigor of the smooth muscle of the swallow. If it's great to of 10 or 20% if you get less than 10, Sewall's is greater than 8000. Then we can consider this jackhammer. If the distal ain't see is normal and irp is normal. So you got Paracelsus. I r P is normal, So stuff is L. E s is relaxing. Allow the content to move from the esophagus down to the stomach. But you got a huge amount of vigor right here. Often you'll see this when people have non cardiac chest pain, you'll notice this This tends to occur, but also as you member from webinar one. Sometimes the longitude muscles will shorten as a circular muscles will contract. And as you see right here, the L E S is is basically shortening a little bit. You can kind of see this angles where it's going up, and it's coming back down here. So generally with people who have jackhammer or even some soft distal esophageal spasms, you'll see some shortening where the basically the esophagus is shortening, then it'll come back down. So not even waiting, not even knowing you have to wait to you see this type of color pressure to start another small. You wanna make sure that this is also coming back down towards relaxation? If not, if it's not, When you do the editing, you wanna make sure you adjust your L E S E G J bars to accordingly where the Elliotts is actually, at next, we're gonna look at minor disorders, appear sauces. And this is basically where most of the most of the reports that after you do the Manama tree will come back as if one of these three things especially ineffective esophageal motility and normal these are these do occur, but they don't caressed commonly as these. So basically the ineffective esophageal motility is where 50% are ineffective swallows. So you're we're gonna look at the D. C I for that. The fragmented Paracelsus is 50% have greater than five centimeters brakes, but they're not ineffective. So they were gonna look at the D. C. I also for that. So again, that's basically another little cheap sheet for you to have. But the big point and this one is that ineffective swallows are either failed or week by this D c I. So we need at least 100 millimeters murkier pressure to recognize the pressure for D. C. I. So if its 100 or less, it's just a failed swallow. It's 100 through 450. We're going to consider that ineffective? Um Sua Also enough, bigger. The range goes from that 450 up to that almost 8000. So here's an ineffective esophageal motility. Swallow as you see again, five of 10 or at least 50% of the swallows that you're able Thio acquire need to be meet this criteria. The air P tends to be normal almost all the time. But in this you see this big break in here. So it's basically a swallows are less than 450 but greater than 100. The fragment of Paracelsus again. Five of 10 or at least 50% of the ones that you were able to acquire the mean d c. I has to be greater than 450. The IRA p will always be normal generally, And then you get this huge break from the stride and muscle beyond the transition zone Thio where the smooth muscle or the trough starts. So this is a really good slide right here. I always another little card I make for new staff members. So as they walk through there, that can kind of like circle or check and take a little tally of each individual swallow what each of these characteristics are. So I just want to point out a few different things. We talked about the deejay morphology a little more thoroughly. Few slides back, but here the big points here are talking about, um, you got to be greater than 100 for the d. C. I didn't even register. Ineffective is, uh, 100 lessons about 450 normals. 4 50 thio Right under that 8000 marked and hyper contracted. It is that that jackhammer is stuff greater than 1000. A big thing about contracted out patterns is this desolate? See point premature is anything less than 4.5 centimeters per second again, Fragment is big point. Here is far greater than five centimeters at ah, pressure contrary or greater than 20 and again the d. C. I s be greater than 450. Um then intact does not meet any of the three force of basically normal. Then interval is pressure. We didn't talk so much about that. But intervals pressure is another. Looking at compartmentalization within the swallow itself of the sailing. If it's emptying into the stomach or not, this is the contour plot where we're gonna put isolate around the D. C. I basically 30 millimeters pressure, and we're seeing if the bullets actually has, um, uh, cleared or not cleared. And we're looking at how much pressure that is? Uh, contained inside the esophagus is talk about compartmentalization mostly occurring during outlet obstruction. Before we go on the editing, uh, briefly talk about the steps for editing. Does anybody have any questions about the Chicago and the terminology and the meta metric tracings we just reviewed? We have a couple questions. Um what conditions other than actual Asia, have you seen associated with a Paris Telesis? I'm sorry, John. I missed the last part of that question. The Eckel Asia Paracelsus. What conditions other than ankle Asia have you seen associated with a terrorist, Al sis? Yeah. So, generally you could get absent. Paracelsus and normal Ira p, um also split. People with scleroderma will show striated muscle like the U. S. Opens that stride and muscle right under the distal border of the U. S. Will be present. And then there will be generally know Paracelsus and then the l e s will be very, very weak so I would say scleroderma, folks, It's a very common to see that also. All right, um, generations have one more point. Vascular damage I would give them when you're when you're doing, um, soft German, um, translator during our patients often give them a lot more fluid or a little bit quicker when you're placing it. Because, um, it tends to be a little bit of challenging getting down because of the absent Paracelsus. Alright, Can patients have combination disorders? And will that be evidence in Chicago classification? Yeah. Often they can have that. But when you employ the Chicago classifications, that's why they have those demarcation lines of at least 20% of the swallows or at least 50% of the swallows on they get borders like, uh, D c I greater than 100 but less than 4 50 or 4 50 50,000. Often you will get that combination even down to the normal, where 50% of the swallows could be normal, the 50% could be like ineffective, and they would still be considered normal So often, when you're going through your 10 analyze herbal swallows, you're gonna see a combination of some but it won't. They won't meet the criteria of the demarcation of the 20% or 50% of the D. C I point or two distillate and see demarcation of 4.5 centimeters per second or the I R P. So there's something there is not meeting that criteria for Chicago. But often you'll see concomitant type of swallows during during the Manama tree. Good question. A very good question. If there's jackhammer with high IRP, how do you interpret that? If it's jackhammer with high R P I. R P. For example, if you have jackhammer and it is Paracelsus, so is greater than 4.5 centimeters per second. But the I R P is, uh, the median I R P of the 10 analyze herbal swallows is greater than 15. It would it would be categories in that outflow obstruction with jackhammer presence. Uh huh. What is the significance of fragmented Paracelsus? Well, it could be the significance of it all. It could again going back to webinar one. You know, doing your pre procedure homework. Talking about symptomology. Often, people sometimes will feel a little complaint. I feel like I get stuff stuck here and eventually will go down. So knowing that criteria a little bit of the story, the background before they come you could you could you could you could, um, hypothesized that the reason they're getting that, like a piece of pulled pork or that snicker stuck in that region right here is because they're having that fragmented Paracelsus. They're not having that circular contraction and launched, um, muscle. Kind of working together to pull this bowl is down so distantly. So it's more about knowing the homework, you know, knowing the patient will be before they come. They kind of give some evidence for some of their symptoms. Why they may be coming to your lap for the Manama tree. Good question, though. What happens when there's no parasol? Tick break? No, period like the whole thing is this. There's there's no transition zone. I'm assuming they're talking about, um, something. You'll sometimes see that, but more often than not, you'll see a little bit of a transition zone from the strident muscle to the smooth muscle. But more often than not, you'll see that, um, it may be that you just you gave too much of Ah instead of five MLS. You were given a little bit too much. They may have a hypertensive U s kind of pushing it down quickly. It's not having a chance to have that natural transition zone, but more often or not, you do see the transition zone in the Swallows. I hope. My answer they were, And that was the question. They were answered. Asked. Okay, what about Nutcracker? Esophagus? Yeah. Nutcracker esophagus. That goes into that D C. I. Where, uh, continuous contractions that generally last for a long period of time greater than the 32nd window. Um, often those people, especially the supine position you may wanna You might want to bring them back up to the operate position that that will tend to decrease those, uh, you know, pressure strong pressure contractions for a longer period of time. But those tend to extend for a lot longer, and also the U. S tends to, you know, kind of do that little that parabolic wave type of thing. Also. So, um so those are kind of the common characteristics when you're actually trying to acquire the sewall's and what to look for, and often it takes a lot longer for that l e s to get back to that basil level prior to the swallow. So that's why all those tests tend to take a little bit longer, because you you're more of a waiting period and people tend a clear their throat and double swallow more often during those type of studies. Can you talk about the potentially higher IRP with the diverse attack healthcare system and whether, ah, they should be using 15 or 20 millimeters of mercury? That's a good question. And people, this is something people should be aware of, like especially allied health professionals that are doing Manama Tree should be aware of because each individual catheter is, um, was adjusted our adjusted or basically, um, tested for that specific number for specific catheter. So even though, like one company, maybe 15, 11 maybe 20 you should use the whatever the manufacture of that catheter is. But either way, you could just instead of in the Chicago, they use one company, and that's why I was 15. But when you're doing diverse attacks, if you're using 20 that you should just put 20 and where that 15 is and I R P for the Chicago Classic Asian because each catheter is specifically designed to that software for that type of pressure. Uh, demarcation line. Really Good question. I think it's really important. Whatever equipment one buys to read all the literature I A fuse, you get with your equipment and then make adjustments due to the catheter design of that individual, um, software program. All right, I have a final question. If the patient has non cardiac chest pain and the e g. D is normal, but the physician recommended motility study E g g s normal non cardiac chest pain. Often in our practice, they would order in Asafa Geo Manama tree and a ph test study. So, Thio, verify if any reflex eight or anything moving Emini from the stomach into the esophagus, it correlates symptomology wise with that that chest non cardiac chest pain. I think that that's definitely very reasonable approach. All right, so we're gonna This is kind of the prelude to webinar three next Tuesday. These are the steps for editing a high resolution stop Geo Manama tree next week will employ all these through a normal swallow. But we just want to get you ready for next week? Azzawi start to review a normal swallow normal study. So in order, these are the orders, uh, to actually review a study first thing after you open it up, you'll see the total study here in time. But then you'll see all the thumbnails of all the swallows that you acquired. But the first step is that you need to thermal compensated. So you see this at the end of the study. If you toggle tour at the end, you'll see this this thing called compensation. Here you can click and drag it, but you need to move this over nearest to this. They call this waterfall that and you can expand this out. But this is when you're pulling the catheter out. You want to get it closest to this point where there's a pressure and this and this is ambient pressure so will compensate from outside the body from inside the body. Step two is, then we're gonna open up the rest the resting window, and then we're gonna basically adjust these bars. As you see, you have the the fair next region, you have the U. S. Region, the body region. You got the L E s and the E G J version and then the gastric region Over here on your right hand side, you can you can adjust these but, um, it said it's negative. 10 The 1 50 again Super red is the highest pressure. Lowest blue is the lowest pressure. Then the impedance is also set and you can you can A justice also. But remember, as in webinar one, we're going to really look at impedance from the conventional line tracing to make our assessment compared Thio the Sava Geo Manama tree. Klaus plots. But we can qualitatively look at these, but more we're gonna beam or in the conventional line tracings for these assessments. So basically you want toe place the bars isolating to you? Yes, the L E s and E g J region. Um so when we could start to analyze it, this is what we're gonna want the software thio basically assess For us, the blue dot regions mean the high pressure zone in these two specific locations. The next step, we're gonna go through each thumbnail that we way we collected. So we're gonna either delete them. We may may need to make some adjustments. Remember, when we're trying to collect swallows, we wanna try thio, start to swallow window, then give them the Bullis. But sometimes, for whatever reason, you just don't do it or forget or whatever it is, as you see in this window, we're gonna make an adjustment. We're gonna toggle in this swallow window to a couple centimeters before a couple seconds before the swallow was initiated. So we're gonna go through all these swallows, get rid of double swallows, Um, thes make some adjustments here. We may have to add some because we forgot to put the measurement window in there. But we're gonna go through here qualitatively and just review each thumbnail or what we collected, um, to make see if we have to make any adjustments. The next thing we're gonna do is we're gonna access for any of these red dots. The red dot will be present and a couple of different areas. The first one will be present in the fair next region. If it's outside the range, um, that it's basically not recognize the software is not recognizing it. We're gonna bring this down just a centimeter or so until the red dot goes away and that's basically the software is letting us know that it's now recognizing it. It could be analyzed, especially for bolas clearance. There's a couple different ways on the software. We can go this window up here in the upper right hand corner. I'll show you here in a second, then we could just move to the next red dot to the next red dot to their next red dot. As you see here, way assessed here we was too far up outside the fair NGO region, so we moved it down and now it's recognizing it. Um, here. But this is these are considered the ones in the body, the Sava geo body. You see, there's very high up and just can occur when people have hernias. Um, they could also occur when people have really long esophagus is. So we're gonna need to pull these all for these down into the SAF agus body. And as you see a Z, pull these down into the region and separate them, you know, try to separate them equally if you can. This is allowing us now, Thio, remove these red dots and allow us to again assess for Bolas clearance. There's again as the top red dot as we move that down into this Ovidio body here is too high for impedance data to be acquired and analyzed as we pull that down into the esophagus body using unequal distribution, I always say it's a good common thing to use. Equal distribution doesn't necessarily need that be done. If you have a really short esophagus or so but equally distributed as long as they're below the distal US border and above the lower strategy approximately border, you'll be okay to analyze both clearance. The next step is that we're gonna go back to the resting ah, window. And then we're gonna open up metrics and this is gonna allow us to see um uh, some values were exactly where we're placing different measurement boxes to review these as especially during individual swallows. Also, you want to get everything into a quite you want to justice these bars. You don't want any pressure, especially during the resting pressure. This is Asafa Jill Body baseline. You don't want this in a pressurization area. You want to move this to a quiescent area are very, uh, blue area and low blue area because right now, this is basically probably cardiac or some maybe persons put their hand on their belly or something. Get. But you wanna put this in a quiet in here? Yeah. Same thing with the fair and Jill Baseline. And then, um then the gastric baseline. You want this down? Also in the quiet. It's an area within the low three centimeters. Remember, we're trying to get three centimeters in the gastric, at least two centimeters in the Ferengi. Your region. The next step in the resting phase is what we're gonna do is we're gonna assess where the pressure inversion point is. So basically, we're gonna take that black line. We're gonna bring it all the way down to the bottom. We're gonna work our way from distal to proximal or from the bottom up, and we're gonna pull this flying back up and you can kind of see these little waves there are occurring. And then as we pull this up, you're gonna see eventually they flip on top of each other or sometimes they'll say it's a diamond again. If the E g j morphology is type one where the diaphragm Delhi s on top of each other will be very close to each other. But as the diaphragm and lower esophageal sphincter sense to separate these, the pressure version point will be located more near the diaphragm than it is towards the L E s. The next step. After assessing again all that set for the resting, um, measurement window, we're gonna go through each individual Sewall's that we acquired. Here's the tricky thing. I think a lot of people get a tricky thing. But one thing people get, uh, don't do actually, sometimes just because you set the resting measurement baselines and the proximal in just the borders of the L E S E g j upper esophageal sphincter throughout these swallows, as we saw during the Chicago thing classifications is that it could shorten. A lot of things can happen depend on what type of swallows you're getting. So you have to review each individual swallow, make fine adjustments if you think they need to make fine adjustments through this wall. So you can't just kind of toggle through these because you set them all these baseline markers In the resting phase, you gotta evaluate each one individual swale that you are that you think is analyze herbal throughout the study. After you get done with that, you can hit save. I'm a big believer on every two or three swallows. It save every two or three swallows. It's safe. It's safe. It's safe to save as much as you possibly can. Um, this for some experience from myself. Over the years, we've had power outages. We've had people walk behind the equipment and unplug it. And then basically, you just gotta start all the way over. Especially if you do a lot of teaching for, you know, other allied health people, fellows or physicians or visiting professors. Um, all these little things can occur so more you same or you say the less you have to go back and redo. The last thing up here is we're gonna hit, generate report. And this is after we get done analyzing all these, a report will be generated looking at the Chicago of classifications based on all our demarcations where we put all the borders are and all the proper metrics. So basically this editing steps and review this was more of a set up for next week as we walked through. Ah, completely normal swallow within the resting window. After thermal compensation, we're going to set the U S L E s and e g borders. We're gonna review all swallows, resizing, deleting, adding in putting annotations like someone may a bomb. If someone was coughing all these type of things that the interpreting provider may think is necessary to add to their note, we're going to assess for adoptive present. Then we're gonna open metrics. We're gonna just all the baselines, make sure they're in the quiescent area throughout each one of these regions because this will represent are the baseline for all individual swallows. As we work our way forward, we're gonna locate in the pressure version point and the resting thumbnail. We're going to review all the individual Sewall's safe, safe, safe, safe as you go through it. Then eventually generated report, um, for the physician or interpreting provider to see. But the interpreting provider. Even though there's a report that's generated, Andi could be printed out. It is a very good practice that the interpreting provider go back and adjudicate all your met all your markings inside each individual small and then if they have to make any few changes. Then they can also hit report if they if they think that your baseline or something was off. But each individual interpreting providers should adjudicate each one of your individual swallows before signing the report. So in summary, you know, using standard high resolution anonymously allows you. Protocol allows you to use the Chicago Classify classification. There may be some adjustments, you know, like they're one question. Can someone what happened? They can't go down all the way or that type of thing. But again, you can more likely employ the Chicago fascination. But just knowing that it was all done in the supine position, enhancing your knowledge of Manama tree terminology improves your technical acumen. Then performing a consistent editing protocol like these nine steps throughout each individual's test that you review or and in each individual swallow and all the other things that occurred during the Manama tree will improve your report, especially the quality. Well, I appreciate everybody listening to webinar to I'll take any other questions for the time we have left. And, uh, look forward to reviewing a study with everybody for weather and our three next week. Thanks, Jason. I have a couple questions for you during the Manama Tree study. Is it necessary to enter comments such as What? Versus dry swallow, coughing and talking etcetera? Yeah, so I'm a big person on editing. I mean annotating. So I I annotate the location in the type of provocative swallow that we do beyond the 10 Analyze Able Swallows. If there's something that may just look on, like someone like coughing or burping or something like that will put a comment in there. I think that's a good practice. Specially, I'm a big I'm a big. How I teach my staff is that after you do the test, you added to study. Then you move on to the next person coming in. So but some people do all their editing after the day's over, so they could done 23456 up to eight a day, then having to remember all those fine little things that occurred during the one at eight o'clock when it's five o'clock in the afternoon can sometimes provide a challenge. So I believe in annotating during the test. This is the best scope of practice type of thing. Alright when saving the changes made interview. Can the original measurements be recovered later, or is it over written? Yeah, you can. You can go back to the original, um, raw data. Basically type of markings. There's the software allows you to do that. If, say, for example, if you're using you have a good study, and you're going to use it for teaching. Especially fellows. Are other staff member just hiring with you? Another Allied health person? You could make a folder, generate that one back to the original, um, demarcations and metrics and then have someone do it and keep yours as, like, the teaching proctor ship one. But there's a way you do it. We do that quite often. We have a huge library of for teaching purposes, doing the exact same thing. All right, I have one last question. Can we go back to the red dots? What? What is the value and the importance of moving the dots? Yeah. So the value for the fair and geo red dots is that is a little bit less important than the Sava Jill red dots. The fair NGO dots will just allow all the fairing Jill assessment of basically Bullis transit to occur, but the south, the south of Geo baseline red dots. Moving them down is really important for assessing bolas clearance of the impedance tracing. So you wanna make sure they're all in the Asafa Geo body before doing any evaluation for the bulls transit? Bolas, Clarence. Jason. Generally, the red dots occur when there is, you know, very short of short esophagus or along. Uh, esophagus is not very common, but just keep in mind, you have shorter along than you're more likely gonna have some red dots. Toe adjust will be one more question. How do you measure Elliott? How do you measure Elliott's the baseline, Elliot? I'm assuming I believe so. Yes. Yeah. So the baseline Elias is first measured in the resting window. What? The basil is at rest. Um, then also it is when you do to swallows the baseline, um, pressure is really not so much important during that swallow per se, but it is important to know when the next swallow may occur again. So during the resting pressure arresting measurement thumbnail window. When the in the swallow, nothing else follows our current, it's basically totally at rest. It will assess the resting basal pressure at that point. Good question. Now. Good question. All right, well, thank you, Jason, for your time. This concludes our webinar test protocols, Chicago classification and editing steps. Please join us on September 15th from 4 to 5 p.m. Central time for the next webinar in the Siri's where we cover editing a normal study. Thank you and good night. Created by
