Chapters Transcript Video High Resolution Esophageal Manometry – Start to Finish Webinar Series (3/4) Editing a normal study. Yeah, until mhm Hello and welcome. I'm John L. Smith, the marketing director here, A diverse, stuck healthcare, and I'll be your host today. Diverse Deck Healthier is excited to present our webinar Siri's high resolution of half a gentle Manama tree from start to finish. Today's topic is editing a normal study. 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 and Charlotte, North Carolina. He's a frequent presenter at national and international annual scientific meetings, and he was elected as a council member for the American Euro Gastroenterology and Motility Society. A few quick items before we begin this webinar is being recorded and will be uploaded to diversity at university. After the Siri's has ended, your microphones have in muted for the duration of the webinar. If you have any questions, please send them at any time. The other questions box on your go to Webinar panel, and we will answer them during the questions and answer session. At the end, we will do our best to answer all of your questions for those individuals that did not get their questions addressed, we will respond to your questions. Once the webinar is over, I will now turn it over to Jason. Well, thank you for everybody joining us for part three of this Webinar Siri's, um, moving forward to actually editing a normal study and working through that process. And then next week, we'll look at, ah, Syria that abnormal studies and editing, um, protocol for that which is the exact same thing, but a lot more review of the individual Chicago metrics. So three major objectives for tonight is we're going to review the protocol, the importance of standardized protocol. We're gonna review the editing tips for Asafa Geo Manama tree and then we're gonna walk through a normal study and of editing to report. So again, the standard protocol is highlighted in purple Here, This is what we are required Thio collect and acquired during the study to employ the Chicago classification the ones that are in black or the provocative swallows and those are adjudication of to adjudicate anything that we find in here but the North. This is this standard protocol and purple that we will require Thio collect during Manama Treat employees Chicago classifications. So the Chicago classification again. Is this here? Arterial model ranges from disorders of e G. J. Outflow obstruction happens to major disorders of Paracelsus, the minor disorders of Paracelsus and normal study. We're gonna look at primarily concentrate only on the normal study today and next week we'll look at one from each one of these other categories of the Chicago classifications. So steps, we're gonna kind of review the steps for editing a high resolution Asafa geometry that we looked at in webinar to before we go on to the actual study itself again. Getting the first step is the thermal compensation that this is, um, identified at the end of the study. After the catheters pulled this company called the Waterfall. We're going to need the thermal compensate for the temperature outside the body, too. Inside the body of the pressure sensors on the catheter. The next step, we're gonna adjust these regions right here the upper esophageal sphincter, the sovereignty of body, the GJ and lower esophageal sphincter. We're gonna just these if needed, then the high pressure zones of the L, E s and E d. J within the resting window. The next step, we're going to toggle through each one of these thumbnails to evaluate. If we need Thio, adjust these swallow boxes, get rid of them for a reason, or so it may be even put. Some notes in thio identify what may be happening during this study. After that, we're gonna identify if there's any red dots there could be fair in jail. Red dots there could be in Asafa Jill red dots, and we're gonna make some adjustments so we can eliminate these red dots to further onto our analysis. And here we go, we have we're gonna have We're gonna have some red dots in the lower in the socket io body itself, and we'll make those adjustments, um, as accordingly. Then the red dot Well, basically, after we adjust this to make sure they're all in in the Penis, chance are all in the esophageal body. The red dots will be eliminated, as as you see here, we're gonna move these down and eventually had the red dot we eliminated, going to try to make them equally distributed throughout the body. But it's not absolutely necessary, especially if you have a very shortest off of your body or even a very long Asafa Geo body. The next step we're gonna open up metrics and that's gonna allow us to calculate every adjustment we make through the resting pressure. Enter each one of the liquid swallows the next step we're gonna edit as we're going. Thio identifier Pressure the pipe The pressure inversion point That's basically where to enter thorough ASIC pressure and entered ASIC Pressure flip on top of each other again. Normal study thinking about webinar one and two when we talked about the GJ morphology remember e g morphology type one will be basically where the L E s and the diaphragm are nearly right on top of each other are very close. So we're gonna identify the pressure version point and then next thing, we're going to review each individual swallow to make fine adjustments to them. Um, to make sure that our metrics are very rigorous as we populate to generate the report we're going to save, we can save many times. It's really important to get in a fashion of saving and a regular time point and try not the way to the entire end, just in case of power failure, Any other software glitches. It's saved at the point where you were at an analysis. So save your time not having to go back. Then we're going to generate the report and then review the report. Um and then, um and then we'll finish for the night, Look forward to webinar four. So again, editing steps and distant reviews, a good window slide to kind of print off until you get into a regular process of editing these and I would recommend doing this same process regardless of the study being normal or abnormal, or short or long. So you can in a very rigorous plan and protocol. And it really eliminates the chances of missing are and performing more of a poor quality editing process. First thing, we're gonna basically adjust the U. S. L A s and e g J borders. We're gonna look through all the swallows. Make sure you don't have to resize them, delete them at them. Maybe you do some meditation. We're going to assess any red dots and move through the study of and adjust each other red dots. Next, we're gonna open metrics. Then we're gonna go back to the baseline. We're gonna just the baselines of the fair and geo body and gastric. We really want thes baseline measurements in a quiet area. It's quiet. Possible. Remember Manama Tree Red color is representing high pressure. A blue pressure is representing a low pressure. So we want these in a blue pressure zone. We're gonna locate the pressure inversion point on day. Then after that, we're going to review all individual swallows. We're going to save the changes. Then we're going to generate a report. All right, let's move on to actual study itself today. And I'm gonna close this out. Let me open this study up itself. So, first, as you open up the study, you just open up zebu the software. You're going to see this window again. Where we're gonna go is remember proper patient management. Then we got all these studies. This is your repository here. And as we're gonna look for the normal studied down on the window, here we go. We got normal. And if you talk over here, you've got a number of studies acquired. You got one represents something that needs to be done to review. And this looks at a number of studies with reports. So if you click on this one right here, and it hit review study. You get all the patient demographics in here? Yep. All the patient demographics and you hit review study, and then a study actually comes up in complete study itself. So if there's red dots that need to be reviewed and fix this window will come up, it will show you that there is critical red dots somewhere in the study, and we look through those and find where those air at and adjust that as necessary. So the first thing what we're going to do is we're gonna move towards the just the land of the study, the very end of the study. So I like looking at in two minute windows, and you can just kind of pull through the study as you go through this itself and you can click through all the way to the very end again. You see, there's some extra Sewall's at the end on need to minimize. There you go. So then you have the pressure about that. You couldn't see the end of it with the window open there. But you have the thermal compensation window. So you wanna move you wanna move this near where the catheter was pulled out at as close as possible, but not right on the pressure, and then it just to the drift that occurred after the catheter is out. So when you take the catheter out, it's a good practice of taking the catheter out, laying it safely on your Manama tree tape. Well, maybe taping it down, not on the pressure sensor itself, but on the catheter body so it doesn't fall just in case some of bumps into the equipment. But you want to kind of close out as soon as possible, so the drift eyes very minimal throughout the study. The next thing we're going to do, we're gonna go back to the very beginning and click on the resting pressure. And this is where you collected the resting pressure in the middle, beginning the test again. You don't need to collect it at the at the beginning, for example, someone has having trouble refrain from swallowing for that 32nd window. You can collect it in the middle or at the end, but it's always good to try to collect it at the beginning, because sometimes the pressures in the U S and L E S may become more hyper contract our greater as time goes on, so it's really try to get to get it at the beginning. Onda also take some deep breaths. Remember, take some deep breaths before you collect the resting pressure to verify that you traverse the catheter into the stomach. So the first thing we're gonna do is gonna just these bars, making sure that the distal and the proxy proximal distal are on the right location again, This is a normal study, so the E g j and the diaphragm del es are nearly right on top of each other. And as you you could pull these bars up if you think it's higher. But if you want to put it right at the top part of the pressure band and the bottom part of the pressure band, these blue diamonds represent the high pressure zone. You want to put that right in the middle of the pressure ban itself. E. J is almost right on top of each other, so there's no separation, so that is good. So up on top of the screen here just wanna go through a few different things. This is the pressure Colorization again. We're on a scale right now. Negative 10 to 1 50 Deep red is 1 50 Deep blue is gonna be a negative 10. The 2030 represent the Essabar Contour basically for assessing for D. C. I on and pressure and tech nous or complete pressurization throughout the swallow itself so and up here on the top of screen. If you toggle over here, they kind of light up what they are. But this is pressure contour the next one over here. If you is impedance contour, then you got convinced conventional wave form. Then you got impedance wave form. And if you talk, if you click on these things itself, they will turn itself off. You click on its back on the same thing. I always like to turn off the purple hue when I'm looking at this, it's easier for me to see if I put the band the borders of these in the correct position. All right. The next thing we're gonna do is we're going to assess any red dots if there's any available. And as we you know, move on. Thio, click on here to see if There's any red dots available, it doesn't look like there's any currently red dots that are going to impact this at all. Yeah, uh, so it doesn't get just any red dots, but we can toggle through each one of these swallows to see if we see any of the red dots itself. We'll be looking for red doubts that show up in the body or in the fair and geo area as we ta go through. I don't see any red dots. Thio, Thio fix it all. The next thing we're gonna do is we're going along. We're gonna go through these to see if all these swallows are actually, um, adequate swallows to analyze the first one. What we're looking for is double swallows. We're looking for only one swallow within this 32nd window. No burping where you see pressure come up and break the US before the the five ml swallow is given. So talk swallow. One looks good. You go to swallow to this one also looks good. It looks like there's only one consistent swallow throughout. Swallow three looks good swallow for but very safe, for example swallow for you Wanna put a note if you click on here, you could put, um, you could write something in here. Let's say let's say Webinar three and you can hit okay to save these notes for you. Um, if there was something that happened during that particular time during the study, you go to five. That looks good. Um, C six here. This is a There's a little bit of breaking here. So if you right click, put the cursor up there. Right click. You can delete this measurement and it will go away. Then the next one. This one also looks good. One continuous swallow through the 32nd window. This one also looks good. This looks good. This looks good, but this one right here, for example, you before clicking on to require to swallow, you gave them the Bullis of the little tablespoon of sailing. But then you click the window. So this to adjust that we're just gonna pull this over here and this This now will look at the view of the entire 30 seconds and primarily just to swallow what we're looking for. You see someone right here? This is a double swallow as you see double but say for example, you thought this was a good small and you missed it. If you're right, click, you add measurement. You can pull that in and then it will actually have to swallow arresting. And then you would click. This is a swallow, but we see a double swallow Here, you see a breaking us here on a breaking us us here and they kind of held down. But there's a little minor break starting to happen here, but we don't wanna analyze that. So we're gonna delete this measurement, go to the next one. Here we go. We see another double swallow one us break to us break and, as you see, kind of delays. The pressurization, especially the distal trough of the smooth muscle and also the L E s is also delayed in opening. So we don't want to analyze these. We wanna right click Delete this one next one. Here's another one. You see one swallow and then here's another one right after it. Within the same 32nd window. We're gonna delete that, and then 10 is a good swell. So remember of it. In Chicago, we're trying to get at least 10 analyze Will swallows in the supine position with that five ml um, solution of sailing before we move on in more. Does anybody have any questions about the editing steps? Um, current so far. And we have some The first one. What is the What is the minimum of seconds needed to consider a arrest window? Interpret herbal. Good question. Um, it's 30 seconds is the ideal range. Um, but you could get away with about 20 seconds, but the goal is always to obtain about 30 seconds. And that goes to the point of when we collect these liquid swallows. It stays within the same front timeframe of 30 seconds. And it also gets the patient also used to that 32nd time frame without swallowing. Um, those air primary reasons why we try to aim for 30 seconds. But as long as it's pretty quiet for 20 seconds, the measurements more likely won't change very much at all for baselines. Good question. Now, another one could double swallows actually be diagnostic if the patient is unable to not double swallow? No, unfortunately. And the reason for that is let me go back to see if you could find that double swallow again. Um, it's a really good question, especially when people are first starting to do this. Um, they'll use some devil Sewall's because of ah, two points. We'll say this is you're gonna analyze this one. The first point you can't analyze it for is because after someone swallow, give that the U. S. Opens and Ebola's comes down Really look driven for is the glut of inhibition. So if they double swale, sometimes this is actually a little bit stronger, and it's a little bit more delayed so that just the Layton sees longer, it could be longer. Um, El es is definitely impacted by the double swallow, but generally I Seymour double swallows in the beginning, with someone just starting to their Manama tree career, is that it? Sometimes I take. It's the most I've ever taken to about 90 swallows to get 10 good ones. Is this more of a patient? Um, thing? Eventually, eventually the patients will get to that 32nd cycle with each other, but often when they're in a supine position, especially people that have more on the top part of that Chicago classifications about outflow obstructions, we'll have to bring them upto let them clear their throat. Then go back down every two or three. Sewall's, um, but, yeah, you don't want to ever use a double swallow as a diagnostics wall. Any other question? Do you feel like your last answer? Um, covered How Thio get 10 good swallows? We have a question. That's what If you're unable to get the goods flows, Yeah, so you can. You can employ the Chicago classification with seven. Analyze herbal swallows. So if you for you know, for example, chronic hiccup er's, it's often a big challenge to get 10. Analyze Herbal Sewall's so you can employ Chicago Classic Asian with seven. Analyze herbal swallows. Um, there's some tricks of the trade to that, I guess probably the most common one is having patients like press their tongue on top of their palate or bite their tongue. Um, that seems the most common first step thio helping people trying not to swallow. But often I think that the double Sewall's and it swallows within 30 seconds happens because the Manama Tree Operator, the Allied Health Profession professional, will have the syringe in the back of the throat when they deployed the sailing solution instead of deployment to their cheek and let them delivered to the back of their throat. It's almost like a proof of air that goes in the mouth, and if you blow in someone's mouth, they automatically have a swallow. So you're almost creating that double swallow just by the syringe technique. Um, I've seen other people bite on straws and then other more often Now, with people with smartphones and that type of thing, you can allow them to put a near but in in their opposite here from you and have them listen to something that they feel comfortable with. Um, they take their mind off that, or if they're streaming a show or something, they can kind of listen to it on their smartphone. So I think there's more. There's partnership techniques that can help you get through that, but the goal is 10. But you can't employ Chicago with seven. Analyze will swallows? Is it acceptable to use dry swallows? Good question. That's a really good question, especially you'll you'll get it where people feel like they can't swallow all five MLS or that tablespoon of swell so you go to dry swells. The reason drives walls are not acceptable is that it doesn't challenge this Safi geo body, especially down here in the lower esophageal. I mean, in the lower end of the Sava Geo body. It doesn't challenge that. So, for example, even when you do, you move on to some of the provocative Sewall's with putting viscous solution apple sauce or something like that. This challenge is is even more so dry. Small, um, doesn't challenge this arpeggio body, so that's E would highly stay away from dry swallows. Unless you're just checking for catheter placement, you could do dry Sewall's. To do that because you're looking for is the distal end of this smooth muscle to identify if you traversed into the gastric region. Good question, though, but I think a lot of people tend to use some dry swells, and they shouldn't that shouldn't be analyzing. Plus, Chicago always used the table the five ml solution. So if you're using dry ice walls, you really can't employ Chicago metrics in the final analysis. All right, what if a patient burps during a swallow is not still a good swallow? No, it's a good question. You'll get a lot of that, especially with people with reflux. Um, some hide a hernia. You'll get a lot of people burping or people a relief Asia, where people suck in a lot of hair. So, no, let's say, for example, the person burps right here then and then you give it the Bullis. This really impacts really the l es when they burp because there's pressure coming up eso that those swallows should be omitted also. All right, last question off. Last question. Are there guidelines available for the rules for the 30 seconds between the follows Is there a guy? Is their guidelines for 30 seconds between each swallow? Is that question The reason for this? 30 seconds from really to 30 seconds? It's a good question because the 30 seconds doesn't really start when you hit the in the software, but you start acquiring the small really 30 seconds starts when the U. S. Brakes s. So it's really 30 seconds from that point. Um, so it's really good to start, you know, you start the acquiring the window, deliver the solution in their mouth, and it's really pretty close within two or three seconds. The reason that is during that glue the glue of inhibition. It takes about 30 seconds for the muscle to recuperate enough like Terry Excite artery pressure in the lower part of the south of your body for the next wall. So then it's pretty much consistent. So if you start to swallow here, but then you start to swallow here. Even on this one, say, for example, this was not a double swell, so it was a single swallow. You see how much of this D. C I is compared to? If you say this was another small how low this D C. Ice, because it didn't have enough time to recuperate that have enough pressurization to be pretty much consistent throughout each small. That's a really good question. I think that happens more often than a few more came in, so I'll just keep moving forward. What if the patient burps? I'm sorry. What if the patient birth after initiation of the swallow but after the body of the soul has passed? Good point. That's a good question. So, for example, if this was the swallow is to say this, let's move over to this one will say this is the swallow right here and the person as the remember This is the deceleration point and this is the distal agency. So basically, the swallows, the swallow has stopped. And now the empty and faces began and say the person burped right here, for example. You could use that as a swallow because it's not going to really impact any of these metrics. But you wanna be cognizant that the next five ml solution you give should start 30 seconds from that belch point. So if say, the belt was right here This is where the 32nd starts not this is not the 32nd window. So it's really where that us was broke for the belch. But it's a the belch. Kurt Gray here in this wall has now completed itself. You could use this swallow, But what you want to dio is that you want to make sure that you Onley frame in that portion and don't frame in the belch right here. If the belts occurred right here, what can you do if you're patient, has nausea during the rapids follows and you try to repeat them. But the patient still has nausea during the acquisition of the rapids. Follows yes, so the rapid swallows is part of the provocative section of Asafa Geo economic protocol. I think it's important, but it's not part of the Chicago classifications itself. Um, generally the nausea. It may be coming from all the solution to sailing you gave before hand eso you could. There's really nothing you can give to help with the nausea you could. It's more of a coaching technique. At that point, you just get the work with them to get the test done. That part of the test done so you really can't really help their nausea. You may, you may, if they have to burp or belch or you may have them. If they want to try to spit up in a vomit basin to try to clear some of that, maybe that make them feel a little bit better. But there's really nothing you can do to help with the nausea to get through the rapid swallows. Besides doing a few techniques like that. All right, that's gonna have to move on. We could take some more questions as all good questions. Um, but I'm gonna make sure we have all good swallows, and it looks like we dio Okay, so we're gonna go back to the resting now. This is basically where we're gonna open up metrics Every time you talk, go on the bars up here, it will kind of let you know what each are. So if you click on open metrics, we're going to get all the metrics now on the right hand side is going to calculate what we have So far, the first window is basically where we're. What we're looking at right now is we're highlighted. So arresting and what we're going to concentrate on here. Is this part up here askew talk Go down here, this arm or conventional, um, met measurements and we could talk about those offline, but we're going to concentrate on Chicago on Lee and then as other things down here, we can pull this up. Its study metrics. This is the resting, and these are it would be all the liquid swallow measurements. But we're going to go through those and they'll change as we make them find adjustments. Then the next one. If you continue to pull this up, you get study metrics, and you can write some notes as time goes on. But just um, for what we're gonna do, we're just gonna pull these down. And we could take a brief look at these as time goes on. But we're going to concentrate on this metric up here, and I'd like to put this just like this. So I don't really see the conventional part, This kind of concentrate on the Chicago the next day. What we're gonna do is we're gonna make sure all these baselines baselines are anchored with these circles are in quiescent areas. So right here, right. If you talk over there, we've got impedance wave form on. And for now, I'm just gonna click that off and all those wave forms go away. So this looks pretty good in the fair. Next area safe, for example. This was down here for some reason, it's gonna calculate every time that you that you changed it. But this isn't in a quiet area because red is remember a lot of pressure. Blue is low pressure, so we're gonna move that up there. The next step here is that you see a lot of pressure in the south of Geo body right around the middle. You can more than likely this is vascular artifact, so we don't wanna put that we don't want to make sure the Sava Geo body baseline is in a quiet area. Then the gastric baseline is also in a quiet area as itself. The next thing we're going to do is put the pressure inversion point. So as you see this black bar, you can pull it up and down and you see a purple line in a blue line to find the pressure inversion point we're going to start, we're gonna go distill the proximal or bottom to the top. And as we're going across this l a s e g j border here, we're gonna eventually see where the Inter thrashed IQ pressure and inter gastric pressure kind of flip on top of each other. We're basically the inter gastric pressure during inspiration is low and gastric pressure during inspiration is high. So we're gonna move and again, remember, this is a normal study, So the gj morphology rebellious and the diaphragm are nearly right on top of each other. And that means the P I P air pressure version point is gonna ride near the dire friends. So, as you see on this one. These colors right here. This little dots inside that. I'm gonna leave this right here for one second. But you see these little doubt the pressure right here through the swallow There's a dot here a dot Here you see, a low blue here, high green here, low blue here, high green Here, this is someone. When they take their gonna breathe in and breathe out, you're going to see the diaphragmatic pinch, so that's going to kind of give it away. If the S and D are on top of each other, we're gonna move our pressure version point slowly up, and then you're gonna basically look for a diamond type formation. And as you see, they're starting to cross right on top of each other. Um, as almost like they flipped right on top of each other. The blues up in the purple is down and you can move all the way up, and you can see the diamond start to happen. So whenever you see the diamond start to happen, we're gonna let it go, And that's going to set the pressure version point general thumb when you have a normal HJ morphology where the diaphragm Elliott's or right on top of each other are near within one centimeter each other. The pressure version point will be plus or minus a half or so Centimeter from the high pressure zone and Dahlia. So just a a target. Thio, look for when you're doing the pressure inversion point, The next step we're going to go through is basically go through each one of these swallows move this webcam over here, all right, And then each other swallows open up. And then again, we're gonna look at the major things in the Chicago classifications we get. We know it's a one. Swallow us opens. This black box right here will represent that D. C. I, um looks like this anchor right here is looking like they think the software looks like it's gonna be a little bit of a break, But remember, we're looking about five centimeters. The circle point right here represents the deceleration point off the swallower and part of the swallow, beginning part of the emptying phase. And then this this little right angle type of anchor allen wrench type of bar is going to represent that Just the Leighton. See this box right here represents the l E S E G J C. How the And then this one represents the gastric pressure. And as you see right here, it has a say. This person looks like they took a deep breath during the swallow that also represent the e g j going down because of the diaphragm Also going down. So that's all in. Um, all those are all good metrics. And as I pull it, pull up over here. We have some with the i r. P. Remember, that's the integrated residual pressure. How much relaxation it's occurring for by the bowls. Force going through the l es on. Remember each software and each catheter has its own, um, demarcation line. This one is 20. So it gives you all the metrics calculating here the D. C I. The inter bullets pressure If you click on here compartmentalization e g j pressurization normal or pan esophageal. Remember, if you have a swallow that has normal, distant wait and see and e j and I are p is relaxing. There's gonna be very limited of any of these other things. But we're gonna talk more about these in the webinar for because it will be impacted by the different facets categories. Categories of Chicago. They were just click normal here then. If you scroll down here, we're gonna It's looking for bullets. Transit. So then, if you click on impedance, wait for him again. Remember both from Webinar one and two that the bullets of the sailing has more resistance than air and sterile water that the bullets is gonna bypass each one of these impedance channels. There's as a more resistant, more resistance. The wave form is gonna go down, and then he's go down at least 50% and then come back to near baseline and shows it bypass that sensor primarily. We're looking at the bottom to this one. Entry came in and you see these anchors right here representing where the bullet came in and bypass that sensor so that we're gonna agree with that, that the bullets did transit. Same thing. We're just gonna ta go through here again again, saying we have if you want to take off the impedance way form. Look at the Chicago metrics itself First without the impedance wait for measurable is transit again. This looks like a little bit more of a pressure break is you see, over here it's measured at 3.2. So that's significant of greater than five, then D. C. I is right here. It's remember normal between 4. 50 and 800 then this is somewhere in the middle there. So we consider that normal compared to the last wall. As you see, there wasn't a deep breath in there. So as the l e s and E G j r. Now the box is much smaller than the previous wall. Thanks. Say again, Can't get me move this webinar box, by the way. All right. Sorry about that. The webinar box keeps going in the middle of the screen here. So then, if you put on the wave form here again, we see the bullets entry and exit entry and exit, entry and exit. So everything looks like it's in the right frame. There's equal distribution between these baselines, but you can pull these down if you want. It's not gonna impact too much at all. But you want to make sure you wanna make sure they're all in the south of your body. That's the key to, um evaluating those those equal distributions as again as we talk. Go through. We did a good job of editing. Which ones should be in which one should be out. There seems like to be very limited or no adjustments at all. We're gonna I agree that this box is in the middle of the, um el es e g j ranges to the d. C. I this break again a little. It's a little bit of a break, but not significant itself. And again, if you have you need to make any notes. You can make any notes you can write whatever you like in here. Say, uh, patient had a hard time. Um, swallowing or something like that are from the previous question. Nausea. Then that would be for Aziz. You look through them again. You can see there's a little note for you. Thio refer back to why that swallow Maybe a little bit different on what the patient may be feeling that is different than any of the other swallows. And again we see that bullets enter and exit pass each one, um so we can go over here and we well hit normal the next. The next one is the next swallow again entry and exit of the Bullis passing each one of the PDS channels. It's bypassing the esophagus into the stomach. So we're gonna say intervals. Pressure is normal on this one. Also, it's really important. And it seems tedious as you go through each one of these swallows. But as you work your rigorous protocol process of evaluating each study, this will be very beneficial and advantageous for you, especially as the studies become mawr abnormal than normal. Um, primarily, I would say you're gonna get a lot of ineffectiveness opportune motility, which will will briefly talk about next week. But when you start to get more of the major and minor swallowing disorders, especially with Paracelsus having a rigorous process of how you do this will provide you a satisfied, high quality way of analyze each individual study regards that's normal or abnormal. So this one, it looks like it's the box is a little bit movies you can you can move the box up a little bit. It was a just the box itself here to incorporate a little bit and that generally the deep. Our contract deceleration point is usually about two centimeters above the proximate border. You put the aliases for a rough estimate. But as you get to other abnormal studies, you'll see this Will author changes? Sometimes it even floats down into the L es itself. And this all looks good again. You see, this one Delhi has is shorting just a little bit. But not enough to adjust the box right here. All these things in a good order, you can see the bowl is coming and going as this one right here, Ugo, enter and exit, entry and exit. So we're gonna click that The bulls did clear any questions so far as we toggle through those 10 swallows, can the p I t b above the al es? Um, not necessarily because the diaphragm would have to be above Delhi s. So generally, no, it's generally, if anything, as they start to separate that morphology start to separate. It would be mostly below the L E s unless the diaphragm pushes further into this office, which which is very uncommon and rare, is morally below the L E s. But it could be it could be a half a centimeter or so above the high pressure zone in the L Yes, that's possible. But not not dramatically above Del Es. Can you make a note on a swallow while performing the study? Um, yes, you could. You could annotate during during the swallow itself. Often we annotate during swallows. Um, actually, that's probably the best way of doing it of annotating during during the swallow, um, or not having a little scratch pad near you where you can write down a Notre. So if you wanna put in after in the swallow that's on the screen, is there a pressure break? Are pressed all different? Right here. Um, is there it is your correct good call who caught that? It's It's significant. It's greater than at five centimeters. And generally what happens sometimes when it generally happens that the skeletal muscle you could look over here How much further this skeletal muscles down compared to this one? Um, since we went through most of them and there was, there was only this one is only one of 10. It didn't have the significant break. Um, more than likely, I think probably they just given a little bit less water or against Wallace as vigorously as they did the other. But there is a significant break from here to here. It's almost six centimeters on liquid swallow. 10. The Bolas Transit says no exits. Can you talk more about that? Yeah. Good. Good point. So you see, right? It's all about right here again. It's about that 50% tile. So if you look at the wave form itself, I mean, these anchor bar's right here. You can pull these over, all right? And then you could see that the way for him. It doesn't go down. Very. It's missing. An exit doesn't go down very far. So you can add in. Go back over here and you can add you can add an exit. So, um, to that window right there. So again, we just I just turn over, Turn off the counter, turn only on the impedance, wait for him, and then you could see that the wave form came back near baseline right there. And if you click on now, they have an entry and exit and entry and exit. I just see you can probably just bypass that channel really quick and dip down. Not as robust as the other ones, but the little X right there represents it entered an exit and did have some resistance. Then if you go back over here to your metrics over here, it does now Sable asses Transit. So it's for the software to recognize that you have to have an entry and exit these anchor bars. And the best way to look at that is in just turning off the contrary and looking in the impedance wave form itself. Good question, Sergeant. When we have a lot, Ah, user that says they're doing a lot of studying of the U. S. Can you please review the proper technique placement for editing? Yes. The US, I think, is a, um a work in progress that say the variability in the U. S. Goes from you know, you see normal from 30 to almost a couple 100 millimeters of mercury pressure. I think the key for you, yes itself is that placing the proper anchors to each swallow is really important. Um then the second thing is that you have at least two centimeters up in the fair next region right here, often times that the catheters place where you barely sometimes some of the U. S. Is not present because I think, as time goes on in the future, um, this is gonna This is gonna be much more studied and stuff that especially the relaxation inside the US Here there's a time and component like we talked about in webinar one or two that, as a variant swallows this showed it should open and close roughly within one second. This residual pressure should be very, very low. But people who do have upper esophageal swallowing disorders or sometimes, uh, existing pressure in here and as you open you can open up these windows as faras. You want the sea even further in the study me go over thio swallow here. So someone swallowing right here See how low this blue pressure here But they have some green in here, so there's some residual pressure happening in there. So there's a lot of work being done in evaluating this and relative to different swallowing disorders. But the key for right now for Chicago's make sure you have enough A little bit of space up here. You have the whole us on the screen and the anchor, um, for approximately to the distal are are in the right correct position with the high pressure zone mark in the middle of that pressure band. But the other key is when you're collecting the swallows for collecting the swallows for during the test, you want to make sure you want to make sure the swallows the person's head, is not turning like this or up and down, because if you just turn your head. Either way, this is going to exert greater pressure in the upper esophageal sphincter band. So you want to keep them as closest possibles, being straight and look in their eyes straight ahead. Even putting their kitchen down like this causes a little little construction and the catheter going through to you. Yes, I hope I answered that question sufficiently. When you annotate, for example, Coffer burp within a swallow frame. Will the result in D. C. I include the composite of the Berber cough? Or will the annotation be enough for the program to exclude? No. So if I understand the question correctly, if there was a cough or burp right here and you annotated that the software doesn't really understand, you're just annotated for your own notes. But whatever in this window right here is what the software is gonna calculate. So if if you don't wanna include that one because a copper burp here you would have to delete this swallow by deleting the measurement itself. But annotating itself doesn't allow the software. No, not Thio. Calculate that D c I or any other of the measurements. Could you please explain the C V, C, p and I V p P boxes on the right side of the screen that you're editing? Good point. So let's just finish this last swallow out here you see an entry and exit and entry and exit entry and exit the D C I box. That's good. The l E s E g j box. That's good. Everything looks in a normal range. So we're gonna say here that it's normal pressurization, But as we go up here, we got kind of go through each one of these on the move this over here so I could see that the I r P is again integrated residual pressure. D l is dis Elaine C D. C. I is distilled contracted All Integral Member. That's at composite of millimeters of mercury pressure time, centimeters, time seconds. PBS pressure break. So contract out front velocity was Mawr in Chicago one and two. It's not part of the Chicago three. Ah, lot of it what it did. It was a tangent line from Okay, I gotta move this the way from the tangent line from the top part of the proximal trough for the smooth muscle to the the end of that, swallowing things almost to this deceleration point. And at that point, it was it was it need to be less than nine centimeters per second. So the velocity of how fast you were swollen, but unfortunately, it didn't show up to good and sensitivity analysis related to spasms. So that measurement kind of went away. A zoo Next Chicago version came, came about contract out bigger is basically how how strong it is is, uh was it failed? Is was it week? Is that hyper contract down that goes about this d c. I so as if it's below 450 but greater than 100 that would be considered a week if it's greater than 100 remember, That's a failed swallow, and anything over 8000 goes into that hyper contract. Il Ity CP is basically contract out of pressure Pressure? Paracelsus basically are. The fragmented is an attack. Is it premature? So, in other words, is it broken up with breaks in between? Is it all intact? One continuous sequence or is it premature? Quickly. And that were dis. Elaine sees less than 4.5 centimeters per second. Then I b p p is inter bolas pressure again. We're gonna look at more. Just gonna be more important as next Webinar is that the Bible is being car car compartmentalized inside the esophagus is there, Panesar? Fragile? Uh, pressure contractions. Eso That's what I bp is then bullets transit did it that the bowl is clear the esophagus and entered the stomach. Good points. Good questions. Can we assume high U ES pressures in weeks swallows and low L. E s pressures That could happen again. You want to rule out the whole manipulation of the head itself? Through that analysis, make sure the study is rigorously done with head staying in a very straightforward action without manipulating the catheter itself. But a lot of times when this is weak or failed, and even if this is week down here is that often people will still have their skeletal muscle, and it's almost like having an apple stuck right here. They either have to kind of get the apple out this way. They'll have to get the apple down towards the stomach. So we'll use a lot of pressure to push whatever they feel like they have there down into the south of your body. So sometimes you'll see hyper contract out here, even though this has failed in this is weak or even if this is weak or failed. And this is weak. But especially, you can disclosure Derma people like this is all this is this has failed a week and this is very weak, but this is tends to be sometimes very strong. What if a patient is re flexing just before the swallow? Yeah, so that that does occur. And, um, that is sometimes called the transient lower SAPA chul Think your relaxation or and you may sometimes your t s l e r. So a lot of times this happens with hernia or when you position change people, what happens is the L E s will just transient relax and then a good way to see this. If you If you have the purple hue on, you'll see the you'll see the purple color come up. And then if someone has normal secondary Paracelsus like this would be primary Paracelsus because you gave the bullets but say they reflects that came up out right here. If they have secondary Paracelsus, the U. S will not break. You have secondary Paracelsus. Then it would push that back down into the stomach. But if you see this right before you swallow, you see this Elliot start to get a little weaker. Then get very Peyton. A very quiet isn't. You'll start to see reflects, come back up and then hopefully you have enough Paracelsus to push it back down. But say you gave a bowl is at that point that this wall in particular would have to be omitted from analysis that almost more times than not when you bring someone from supine and if you end up doing provocative swallows in the upright position, you'll see this transitional relaxation. You know, even people who don't have GERD or any um, a priority variables to girl, you know, Hydra hernias and of that nature will thank you. Help you understand, Pianist Safi, Jill and other dysfunctions that useful during editing. I didn't hear what you said, General. The first, the first part of the question. Sorry, we'll think of you help you understand, Pan esophageal and other dysfunctions. Is that function useful during the editing process? Um, I think all computer software algorithms are somewhat useful. But I would I would go back Thio kind of understanding what each metric are and then you being the adjudicator or the judgment if the software that that part of the software is useful or not. But I think learning the rigorously what? What it actually is each one of those metrics. You'll be the better adjudicator than that than than the software itself. All right, we have, uh, remember saying I have been advised that by dropping the Trent chin, the discomfort of the catheter is alleviated. How do we offset comfort and accurate reading? Yeah, So I agree with dropping the chin, um, for placement because that kind of naturally opens up the nasal passage and also starts to have the epiglottis start to move towards the airway. But during the study itself that the catheter is already through the U. S. so dropping the chin, the benefit of dropping the chin, um, to get the catheter beyond its already epiglottis is already up. So, um, I think I think that's I think dropping the chin is more useful for placement. That actually, during the study itself, I would say, if you need to drop the chin for comfort and that's how the patient's gonna feel to get through the study, I would I would suggest doing a little bit of, ah, quasi experiment yourself would have them put their chin level. Then, when they drop their chin to whatever comfort level they're at, I would look at the U S and see how much pressure change I was and make a little notation annotation itself. If it makes it minimal difference, no big deal. But if it's a makes a marketable difference from pressure, and then I would probably try to have to coach them as much as possible to keep their chin straight down straight ahead. But you know, there's some people that have back issues where they're bent over like that already, naturally. So I would annotate that on your test. If you do patients like that that the U. S may be exasperated a little bit just because of the natural anatomy of the patient itself. Because no way you're gonna push their chin back because they're back anomalies. That would probably cause them more pain than the catheter itself. All right, last question. How much time do you allow for each study? Good question. I eso again. Right? When you place the catheter, you want to give a solid we a solid five minutes, so we'll take that. Five will add that five minutes onto the study. If you're just doing this the study protocol that we look at, uh, just thio employ the Chicago classifications. 10. Analyze herbal swallows generally, if you had five minutes, you could be done totally in about 20 minutes, 15 minutes for the test and five minutes for the acclamation period. But if you started to provocative swallows each each of the other provocative swallows, you could probably add another 10. So we're looking at about 30 to 35 minutes if you do all the swallows. But if you only employ the Chicago 10 analyze will supine swallows More often than not, the median time is roughly around 20 minutes and we've done a lot of quality control projects at the places I've been in most of time. It runs somewhere between 18 and 22 minutes because often if you let the patients no. And this is seems simple. But if you let the patients know that the less if you only swallow when I ask you to swallow, the catheter can come out much quicker. But every time you swallow without my instruction to swallow, then it's another 30 seconds. So you could you could see how these 30 seconds can add up over time. So I think if you're upfront with them but going back the webinar one or two where we talked about partnership with the patient, if you're if you're upfront with them, um, generally after, after they get used to the catheter, they get in a rhythm itself. All right, so one more thing we're gonna dio after we're gonna done, we're going to generate report here, gonna pop up, and Microsoft Word takes a few a few seconds. But I have a question Why this is being generated. Sure are viscous follows not used for Chicago. It is not. It is not there was all based on five MLS of ah, normal sailing. Now a lot of people do viscous swallows to challenge the esophagus. Um, the challenge esophagus beyond or do some adjudication off the wet swallows. But my, my, I guess my one and one rule of advice, I guess if you're going to move on to do the provocative swallows, um, in your in your in your protocol you're your own labs. I would do it for everybody. So, for example, I know some places that have the Allied health person decide. When did you provocative swallows when not to do provocative swallows? I think Allied help people. I'm a big advocate for allied health professionals, um, nationally and internationally, but I think, um, that gets a little bit inconsistent. So I I believe if you're going to do the uprights, walls and rapid swallows, a viscous swallows the rapid challenge of 202 100 ml swallow. Everybody does. No matter. If they're total normal study to a total abnormal study, everybody will do the entire protocol if you're going to employ the provocative swallows. Um, that would be my only rule advice. I wouldn't pick and choose in between who gets a provocative swallowing who does not. All right, So after the report comes up, you're gonna it pumps up inward. And if you read up here some compatibility mode or read only mode, you're gonna If you want to change some stuff on you, remove this webinar window over here. If you're gonna change, you want to write some things in. It has all the demographics you put in, um, in the top part, their height, their way, the diagnosis and all that type of things. You're gonna put it there on acid suppression medication. But you get all the measurements from the lower esophageal. Think you're the body itself? Um, the impedance data. And then you say you wanna put in, uh, something here Normal, uh, patient patient expressed nausea or something of that nature. Then you want to save this before to another place you can click anywhere that's on that you feel comfortable of saving. You could be to the desktop. It could be to your local c drive. It could be to, ah, secure drive at your at your location. Um, but you want you can save it anywhere, and you can create folders of different normal studies to, uh, Ankle Asia. Studies out love struck outflow obstruction study, especially if you're at a research institute. But you could do all that then then then. But it's really important. As the allied health professional acquires, the test, analyzes each of the study each other Windows and prepares it that the physician or the interpreting provider also opens up. The study toggles through. Make sure adjudicate your work, agrees or disagree, makes adjustments. Then they generate this report, um, and printed off and do the official sign. They need to adjudicate each one of your swallows in your markings to make sure they agree with you because they may disagree. And it may impact the results that populate into the report so that I know we ran a few minutes over. I apologize, but I still we could an if anybody has any questions we can answer, asked to answer a few more questions. But next week we'll look at abnormal studies, um, income in Esso, in relative to the difference between a normal study we've seen tonight. All right, what is the importance of detecting a red spot? There's two importance of that is that, um for Bullis Transit. Um then also for the impedance channels within the Asafa Geo body. So sometimes the red spot the top part of the impedance channels inside the upper esophageal sphincter range. They all need to be into the the Asafa Geo body itself. And it's good to try to make them equally distributed. Like, you know, 5, 10, 15, 20 It's not necessary, but try to have some good equal distribution between there, but it's about Bullis Trans. All right, It looks like we have one last question. In which case is the Elias included in the D. C I measurement box? Um, that well, I would say sometimes the software may put them in inside that box. Um, probably the only time that may occur is if the deceleration point gets down into the lower esophageal sphincter ban itself. A lot of times, that could be when there's a large hernia where the South Jill bodies shortening eso. Oftentimes it could kind of creep into their because the deceleration point will kind of creep near towards approximate allege or even a little bit below that in the lower soft Jill, uh, sphincter range, the bar. But in those cases, if you could kind of see if you just move that D C. I box is slightly above that, you can kind of see where the angle has stopped. And that's where the swallowing stopped in the empty and has began. This being phase of the swallow has begun, but I would say those are quite rare. But generally with large hydro hernias will be your biggest chance of seeing that type of, uh, depiction in the Manama tree study itself. All right, Jason will make this the last one. If during the acquisition three us is not on the screen due to long esophagus, can you move the probe a little bit out after making the Swallows in order to capture the US follows and the US baseline. Great question. That is a very good question. I think, Um, the way that I have caught this over the years is that you place it like you normally dio at the first and the U S. Like you said it off the top part here, I would collect arresting pressure and make sure you now we're assuming that you traversed into the stomach beyond the G J and L E s. I would collect the baseline. Well, you know, five deep breath there, then a baseline. I would do two or three swallows. Was it right there? After that is over, I would pull the catheter out a little bit where you can. Now, basically, you're going to identify the US itself and induce the rest of swallows. Um, in that position. Um, the key is to get least seven swallows where you identify the l E S E g J without the U. S. Three swallows with the U. S. Um, that's identified on the screen. But if you after you make the adjustments, make sure you do another couple of deep breaths to make sure the catheter is not kinked in itself. But it's really important to it's more important to see the end, the L E s and the distal part of the esophagus more than the top part in relative to the Chicago classifications. Thank you, Jason. This concludes our webinar editing normal study. Please join us on on September 22nd from 4 to 5 p.m. Central time for the next webinar in the Siri's will recover advanced editing techniques. Thank you and good night. Created by
