Chapters Transcript Video High Resolution Esophageal Manometry – Start to Finish Webinar Series (4/4) Advanced Editing Techniques: Editing various abnormal studies including Achalasia Type 2 and 3, EGJ Outlet Obstruction and Hiatal Hernia. Yeah, until mhm Hello and welcome the first sex Health Care is excited to present the last webinar in our Siri's high resolution esophageal Manama tree. From start to finish. Our final topic is advanced editing techniques. Thanks for joining us today. I'm General Schmidt, the marketing director here, a diversity of health care, and I will be your host. Jason Baker is our speaker for the Siri's. Jason is the co motility director and director of clinical research at Atrium Health in Charlotte, North Carolina. He's frequently a presenter at National International annual scientific meetings and was elected as a council mother for the American Neuro Gastroenterology and motility Society. Just a reminder that this webinar is being recorded and your microphones have been muted. All of the webinars in this series will be uploaded this week to diverse a tech university for you to access. 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 as designated times. We will do our best to answer all of your questions and for those individuals that do not get their question addressed, will respond to your question. Once the webinars over, I will now turn it over to Jason. Well, thank you, Juno. And thank you for everybody who has, uh, spent the last four weeks with us on Tuesday night, uh, doing Asafa Geo Manama tree from beginning to end tonight is gonna be less slides and more looking at specific swallows of a Siris of different, different type of swallow images within the Chicago classifications. So a little objectives, we're just going to review the protocol again, um, of a standard Asafa Jill, a Manama tree protocol. And then we're gonna review the Chicago classification, then go on to review in several images. So again, this is a standard protocol again similar to before. What we want to collect. The used to Chicago classifications is what is in purple. The black is provocative swallows that may use for adjudication for major swallowing disorders. Um, one thing I want to make a comment on It was a question from last Webinar three was this five minute adjustment period. Um, it doesn't impact so much. The process of doing using utilizing the Chicago classification Index, but it does allow for really three things allows really most importantly, the patient to get adjusted to the catheter being in their body, the U. S. And LS baselines will tend to get mawr to a quiet. It's an area as later on in that five minute adjustment period compared to the beginning. And also it allows you to build that partnership between you and the patient of, you know, a flexion of voice encouragement and maybe explain a little bit more what's gonna happen as you move forward. So review In the Chicago classification, we've seen this. We're gonna look at disorders with the GJ outflow obstruction. We've seen this slide several different times throughout the last three weeks. In the red box last week in weapon are three that we had the red box down here. We looked at a normal swallow and this week we're gonna walk straight down. We're gonna look stuff into disorders with GJ outflow obstruction. We're gonna look at some images and major disorders of pair of salsas. Then we're gonna look at some images in the minor disorders of Paracelsus and won hyo hernia. So we're gonna start up here in the major disorders, disorders, outflow obstruction which really incorporate ankle Asia subtypes and out E J J outflow obstruction. All right, so we're gonna go onto the actually look at some adventures now. So again, this is what would be pulled up and you pulls the view up. Look at the patient management again. This is a repository of all the studies, and this is nice right here. If you just type in the beginning of a couple letters in your repository, whatever you name them, they will pop up on your left hand side. So when I look at the images of Eckel Asia one and we're going to set the stage for all the swallows, we're gonna look at and within the next 45 minutes or so. But we already set the baseline. And how you did all that in Webinar three. So what? Just looking at these, we're gonna assume that the baselines are already set. We're now we're ready to look through the different type of swallows again. The window pops up about set, tells you how long you did the study. Um, you can get rid of the purple coloring. The impedance value can just click on that that will disappear and then before we move on, I want to describe this button right here. Over here in the left hand corner. You're going to see this little little question, Mark. It's a help button. And if you click on help, they have all these different links to the guide is, uh, the analysis guide of both Reflux and Asafa Geo Manama tree for the user. So these are always good to have and you can get downloading to a folder on your hard drive or desktop. So we're gonna just pop open, swallow one. Remember, Eckel Asia type one. We have to meet a certain amount of criteria again. The I R P, um, needs to be above the minimum of the catheter type itself. So with this catheter, it's 20 millimeters mercury pressure. The D. C. I. It needs to be absent. So remember, absent or failed is anything under 100 millimeters mercury per second per centimeter in the D. C. I. And also, if you click on the box the white, it becomes white. And then you see it also a little arrow pointing to what? You're actually what metric You're actually looking at same thing here with the I r P down in the L. A s region. It kind of populates here. So in actual Asia, type one, this meets the criteria. This purple color in here often you'll see, basically blew very low pressures. But every once in a while, you'll see, like scans, the green, very low pressure. That's probably being some artifact within the catheter inside the body or a little bit of movement of the patient itself. But this was definitely less than 100 so it's it's have failed. It's more from the catheter than actually the physiology of the swallow. So, as you see, the AARP does not relax. It's above the minimum. There's no Paracelsus, so this would be an image of a type one. Um, you wanna make sure you adjudicate each one of these boxes and make sure they're incorporating what you want to see and again on ecology. You won't see any deceleration point or disallow agency because this wall has failed and similar as we go to another one again, we look at this box when I make sure I was that is that above 100? Is that a due to the catheter or just the patient's body moving, um, or the physiology, but looks at its lower than 100. So it's a failed swale, and again we go look at the I. R. P. That's the other metric that we need to meet its above the 20 millimeters Mercury pressure. So we're gonna consider this a type one Eckel Asia. Yeah, than going thio in comparison. Move on to type two again. Just type in a few different letters and however you label them the will populate what you have in your repository and you hit review study again again, we're gonna turn off the purple Uh uh impedance value. We're going to assume that the resting pressure is already completed, and then we're gonna click on the swallow in comparison to Eckel Asia one, You're gonna get thes premature simultaneous contractions really fast, really quick. So the criteria for actual Asia to is basically gonna have this simultaneous contractions. It's premature. It means it's very quick. And then also the I r P has thio be above the minimum threshold for relaxation. So this this realistically and you have to see these in 20% of the sewall's of two or 10 or whatever you may collect with 20%. So, as you say again, you can click on the white. The box it turns white. The marking comes over here. It doesn't meet our criteria for non artifact from the catheter or just body movement. Is Israel physiology of their swallow? You click on down here gives you both the deceleration point, which basically indicates where the diesel agency is. It's very quick. It's less than 4.5 centimeters per second. And what's happening with the I. R. P. The IRA P is remarkably higher than the normal threshold. So this would be a very textbook image of a Nickel Asia type two swallow. Then we're gonna move on to one other one and again just mirrors the one before. So this becomes a natural pattern throughout this person swallows this study we can use in the Chicago Weaken basically state by them meeting the criteria of the D. C. I above 100 that Israel pressure from, uh, simultaneous. As you see, it's straight down. It is premature. So because at the distal agency is less than 4.5 centimeters per second, then what's happening with the i. R. P markedly higher than the minimum threshold and then stating that is his ecologia too. Then if you want to see, we put put over the impedance and we take off, you just click on the box itself. It will take off what you want and the indicated check mark goes away. But remember, in the first couple webinars and even Webinar three when we've seen Bolas clearance as the bullet passes those impedance channel which is mostly you sailing, has to drop 50% below baseline and have an entry and exit. As you see, none of the especially the bottom two is what we're keeping our eye on. Um, that are too above the approximately s is that you're kind of seeing that the bullets has entered and has not exit is entered beyond that channel, but has not exit. So if you go back here and if you turn on this one, you'll see the column is basically just following up filling up with your sailing. So it's another these air, uh, in complete clearance. Obviously, this is known in Eckel Asia, but these are other items that you'll need to look at when you review these each one of these walls as we described in webinar three. So we're gonna move on to the next Actual Asia was just type three and often needs to be the most. Um, uh, reviewed because it could easily fall into, um maybe it could be out outflow obstruction. It could be a distant esophageal spasms. Again, we're gonna assume that the resting we already did that that's all set up. And we know that by the check mark right there that we placed all the markers correctly and we're gonna open up the first window here and again. The criteria for Eckel Asia three will be that it's premature. It's fast, it's hyper contract out. I mean, there's a lot more D c I or vigor of the swallow. Andi. Also, the dire P has it will be above the minimum threshold. So we're gonna walk through a different couple things Between this and a digital south digital spasm that were another. We're gonna move on to an outflow obstruction. But as you see here that the first thing we're gonna verify you have a lot of vigor. You see, the number is now remarkably it's over 8000, so it's a tremendous amount of bigger, a lot of strength happening as a swell. Then if you look click on down here to the deceleration point in distillate, see, as you see, it's premature. Its's faster than the normal threshold. Then we're gonna look at the I. R P box or where L A S E G J. Is that, as you say, it's remarkably higher than the minimum threshold. So it meets all three criteria for a nickel Asia. Three. Um, it swallow image. Then we'll look at another one. It almost like mirrors to the first one. I mean the vigor on this one. If you click on again the box it, I'll highlights the D. C. I. It's even stronger on this figure right here. Is it fast it states right here, yet we're faster than the normal threshold. I mean, this high vigor represents hyper contract Tyltyl, and if you want if you if you disagree with that, you can also change it here. But the software's accurate and the Paracelsus is premature. That means it's lower than 4.5 centimeters per second, so we're gonna agree with that and then IRP. It's remarkably higher than normal threshold. Then, by clicking on the impedance, we're going to see here that the bottom two channels as it passes the saline passes up the more of the proximal, um, Penis channels as it works its way down the catheter distantly enters but does never have a entry exit points. So we're gonna obviously an ankle Asia of all of them. The column is just kind of filling up with the sailing because it's not bypassing D D. J into into the stomach. Let's say, for example, this right here this is the I. R. P was normal. Let's assume that this box right here instead of being 99 let's say this was 15 and this minimum threshold for this catheter is 20. So let's say this is 15. Um, this is premature. This is hyper contract. I'll at that point that instead of being Eckel Asia three, it's gonna be a distal esophageal spasm and the criteria when you walk you through yourself all through these different boxes and these metrics to verify what you what it is, uh, in relation to Chicago is that you wanna use that one slide that we've seen many, many times, and I think I said a webinar, too. It's good to print that slide off, kind of, um, put it somewhere that you can kind of refer back to it as you work your way through and review in each image after you collect the swallows. But if to say again, this was higher, P was normal. It was premature. Hyper contract I'll and it was greater than 20% of the swallows met that criteria. This would be more distal esophageal spasm and then something else that may look like the exact same, you know, exact same type of image. But you have tow, really use that that one slide to verify what where it falls in the Chicago classifications is is outflow obstruction. So if we go toe outflow obstructions image. Here, As you see, the vigor is often a little bit less, but it could be really hyper contract out. The vigor could be very, very strong. It could be in that 8 9000, And eso don't this because this one says 1000. The next one will say roughly about 1000. The vigor could be just as strong as in the distal esophageal spasm. And, um, Eckel Asia three. So if we click on here, we see the vigor is within normal range. What about the late and see right here? Um, it's greater than four centimeters. So now it's normal. The Paracelsus is normal. And then the irp here it falls into above the normal threshold. So with outflow obstruction now, the criteria we're looking for is does it have Paracelsus? What is right here? What is this distant legacy? Um, in comparison to the other one. Remember the other distal esophageal spasm ankle Asia? Three. Um, they were premature. And then an outflow obstruction in relation to in comparison to Eckel Asia three, they both have i R p above the normal threshold for the specific catheter, but an outflow obstruction the dis awaits e is normal. So and then we're gonna look at another swallow outflow, obstruction. We see the exact same thing. Um, that you have you click on the box, the vigor falls in within normal range. I r p looks a little high and we are correct. It looks a little high. You don't see very much relaxation in here is that Eckel Asia three is a disco soft are awful obstruction. You click on that, we need to look over here, point towards, and it looks like it's above 4.5 centimeters per second. So the criteria for this wall would be outflow obstruction. So, some advice as you walk through these Sewall's and you and you after you collect them and acquire them and clean them up by doing a little bit of editing that we saw, like in, uh, webinar three. You wanna you need to really try to decide, especially these ecologia three outflow obstructions. Which one? It is, then, between Eckel Asia three and just south of jail spasm. So before we move on to the next category within Chicago classification, does anybody have any questions about, um, Ankle Asia? Outflow obstruction, maybe distal esophageal spasm? Sure, I have a question on, uh, if you can. You have e g J outflow obstruction with complete bullets transit. You can have that, and it's like it's a good question. So let's look at bullets transit here, especially especially early on you may have we had a This this dotted line is like the 50% outline so you could kind of see it kind of undulating, um Below it and back. It's very, very small. But in outflow obstruction, you can have often, um, Bullis clearance usually earlier on. And the swallows, um, compared to later on in the swallows, because the patient tend to be a little bit more relaxed. But as the boldest pressure, the count basically continues to rise because they're not emptying into the stomach. You get this, This color right here, this orange color beyond behind the wave is called inter bullets pressure. This will start to increase because now there is called compartmentalization. So the column of the solution of the sailing you're getting is just kind of creeping up higher and higher and creating more pressure there so early on, Yes, but generally might experience later on of the 10 swallows, they tend, it tends to get mawr incomplete, and often when you have them in a supine position, you may often have to bring them up to clear their throat. Alright, what happens? What technique to use, uh, when the catheter doesn't pass the e g. J. This is a situation that happens frequently for someone when they have an actual Asia patient or someone with a high it'll hernia. Yeah, well, look at a height of learning a little bit later on. Gets a good question. Um, I think it's a little bit of two different answers Will sit well, we'll stay with Ankle Asia's and Outflow obstructions. Um, with these with you. Remember, in the previous two such an escalation three. It was Marechal Asia to dire P. That was just remarkably higher than a normal threshold. Some techniques I've used in the past is that you could you could have them as you get to the catheter. You can kind of just where you think that is that, um uh, approximately s border. And you can have them take a big, deep breath in then you want right after they blow it out. You wanna have them take a, um, start sipping on the solution. You're giving the sterile water or whatever you're giving them to place the catheter often that deep breath will just relax. The L e s just enough. Whereas they take that drink, it just my newly relaxes. And with your pressure of pushing on the catheter, you can kind of slide the catheter through Thea other way we've done in the past instead of you can have them lie on their back and tilt them underside towards you and tilt their shoulder in and have them take sips of water. I'm just by repositioning their upper torso. 10. Sometimes we'll help you get the catheter beyond that point and then the other one I have less success with. But I've seen it done just a few times, actually. Ironically, two days ago, one of my staff members did. It is I had someone stand up and they raised their head above their hands above their head and we were able to slide it beyond the, uh, e g j. For someone who end up having Ankle Asia Type two. These are all different little techniques to use. But if you continue to try different positions and volumes and deep breaths, um, you could be you could be quite successful at it. But I agree with you. Sometimes it could be a challenge. Okay, this person had a patient that couldn't stop double swallowing, which made it difficult to determine ankle Asia versus E. G. J. Outflow obstruction. Any advice on getting the patient through that, Yeah, great question. That's That's probably the most common thing that occurs. Um, couple things have used in the past that have been really successful with that is having them really pressed their tongue on top of their palate after, um, the five. The tablespoon of sailing is a minister. That may help, but I would also encourage someone to deliver the the solution to their to their opposite cheek and let them bring it back instead of pushing the cath the syringe in the back of their mouth or having them suckle on a syringe. Sometimes people use e think they're called alligator syringes, where they just suck on it. I would those folks that would probably not have them do that, um, similar with Hiccup er's. We have them bite on a straw, so you open another straw, and after they give them after you get this wall, have them bite down on the straw, and that allows limits amount of breathing through the mouth type of thing. Um, then the other things become like music and, uh, watching streaming something on their phone, squeezing on a ball. Um, those are probably secondary, But those first ones, I would try those other first techniques. Um, first, to see if that will least get you one or two swallows and you probably have a syriza double swallows on get another couple swallows, then you know, then you have a syriza double. Sewall's those people you end up probably collecting, you know, somewhere 20 plus swallows just to get to the 10. All right, when you have a pronounced diaphragm pinch, does it affect the I r P I R p? Visually, the l es looks relaxed with the IRA. P is elevated because of the diaphragm. That's a good question. If it's a morphology type one, um, that could impact that slightly. Um, but the RPI really is. There is not someone it zits how much relaxation is required when the bowl is pushes through there. So, um, a pronounced diaphragmatic pinch when its morphology type one kids have some impact on the AARP, but ultimately it probably more of a the contributing factor more than a primary factor. But you have to be very careful of those people that their hands are not on their belly when they're doing the Manama tree. their hands were down by their side because the literature has shown it. Pressing on the abdominal cavity also can impact the GJ pressure. Eso you want those people specifically to have their hands down by their side? Alright, so let's move on to the next Siris of swallows and please feel free to answer any. Ask any questions and we'll get those two at the next Siri's. So the next ones is the major disorders of Paris Tulsa's and what are those again? Here's that slide. Um now, were you see the red boxes around this really is about, um you know, just Asafa Geo spasm, jackhammer esophagus and absent Pierce uh, contract il ity. So again, there's a little bit difference between the box that we saw up there compared to the box our next boxes that the big thing is irp is normal most almost all the time. So and again we saw the diesel esophageal spasms that the difference was that I r p was normal compared to you know, Eckel Asia three type three. So because they both were, you know, premature, often hyper contract out. But this one i r p was normal and up here. Dire p was abnormal. So we're gonna look at a jackhammer and absent contract il ity of a swallow and see some scenes of things we're gonna need to look at as we review these type of swallows if you collect them during a study. So the first one we're gonna look at is a jackhammer. Um, you know, we see these every once in a while, but these are, you know, not very common again. We're gonna assume that resting is complete. We're gonna turn off the purple. We just want to see the contour here. Remember, if you just hover over it, it shows you what this artist is. Pressure contour. And if you click on swallow one, there's a There's a common image that happens when you see Jackhammer ITT's contract. Big, large hyper contract. I'll contractions and they go on for a sequential amount of time. You can kind of see him in order. Big contraction, that a little bit of all big contraction, a little bit of all big contraction. And the one thing we wanna know when you're collecting these type of swallows is that even though the 32nd window box may be complete by time, chronological time. But sometimes the L es doesn't relax to another, you know, 10 plus seconds later, and then that's when the next swallow should be initiated. Just because the 32nd boxes over what's physiology is still occurring, and then we have to understand what is the Remember when you collected the resting pressure? What is that Baseline color pressure before any of the swallows were given? Then that's what you want to kind of keep your eye on as you sequentially go through the test. Just because the 30 seconds was complete, it may not be ready to give another tablespoon or so or five MLS of sailing. So what, we're looking in here again? This is We're gonna click on the white box. Look at the d. C. I were remarkably higher. 13, almost 14,000 millimeters of mercury per second per centimeter. So that is a tremendous amount of pressure. Eso now we're definitely hyper contract out. What? I wanna know what's happened. Is it right here again? He could kind of see that was gonna be greater than 4.5. Wasn't premature, is gonna be great. And 4.5 centimeters per second. And then so then we want to click on the box here. What is the IRP? It falls within normal of this catheter design. So at this point, we see a lot of pressure here. So we can now rule out that we know late and see is normal. We can rule out Akhil Asia and then the next thing we need to rule out looking at the A P. This one is normal. We can rule out outflow, obstruction and also, uh, outflow obstruction so this would fall under the jackhammers. The difference between this and the spasm, remember, to spasm is less than 4.5 centimeters per second with the IRA, PB and normal. So using that slide as a cheat sheet type of thing as you walk through here and you just kind of click on what each one of these metrics are that you're kind of verifying as you walk through your little algorithm and often when I teach this senior staff, we use like, ah highlighter and you can kind of marked down the box count. How many are because there's percentage of these have to meet this criteria. So if say, you're able to collect 10 two of 10 or to release 20% 20% of greater the swallows need to be meet this criteria. And here's a perfect example of this one right here. If you click on that, you can actually probably even pull this. We're gonna pull this slot swallow even over here because you could see that I see where this swallow is continued. This contraction still continue to go, and this was the end of the 32nd mark. But the swallowing of the physiology still occurring of the swallowing part of the emptying phase was just getting ready to start. So if you had initiated another swallow over here, it would still be in the middle of this wall. And then this next swallow would probably be markedly lower because it was still through the exciting story phase of the swallow, but also probably would have been able to be analyzed because of not waiting enough time for the body to recuperate itself for the next wall. So what we wanna do? We click on the white box markedly higher nearly 29,000 now, So it's really hyper contract. I'll is it. What about the distal agency? The diesel agency is above the normal threshold. So what's happening with dire P? The RPI is below the normal threshold. So you know, we know it's not Eckel Asia. And it's not just the esophageal spasm, because this is normal. This is greater than 4.5 centimeters per second. So this would fall in the criteria of jackhammer. Ah, Sophocles swallow. So, in contrast to the swallow, we just saw what jackhammer esophagus? This is gonna be absent contract. Haley, the direct opposite. Remember, by just hovering your mouse above these things, they tell you what there is is a pressure contour. This one here is impedance counter. We're going to turn that off. You don't want to see that currently, and then we're gonna remember the resting pressure is already done. And then what we're gonna look at is this swallow right here, As you see, does it look like Ecologia One? Maybe because if you look over here, if you look over here at the all kinds of windows of there you go. If you look over here at the D. C, Iet's basically non existent that doesn't meet the crowd cheered, even evaluate to swallow. So that also falls in accolades you want. But now we need to find out what's happening and the the air p range. And again, it's 15 below. It goes below the normal threshold. So this now rules out the idea of actual Asia one and now rules into is absent contract Il ity. Um, often if this l e s is, um e j region is very very, uh, week. And then you might see a pronounced little skeletal muscle up here and this is absent. You may wanna when you do your pre homework. When we talked in webinar one, this could end up being someone, maybe with x scleroderma. Then we'll check that What? We'll check the next swallow again. Doesn't have enough vigor. It doesn't meet any criteria to evaluate. Um, it's absent. So is it is it Eckel? Asia want our let's check out Dire p is doing It's below the normal threshold. So this falls into this absent contract il ity. But what's happening is the bowl is clear. Is it not cleared? So what, we're gonna dio hover over here? We wanna look at impedance wave form. Um, then we're gonna turn off the pressure contour. Then you're gonna see it. It's really not clearing so much, mostly because there's not a bigger in the esophagus to push it through. So often people with in my experience with absent contract Il ity is that the lot of the residual of the sailing will remain here, but eventually it will just because you have them in the supine position. It eventually empty into this, um, into the stomach area. But a lot of times there's a very failed bowls clearance. So, um, and then it's usually on the bottom to channel. So you wanna be You want to kind of look at that often on even on the impedance wave form. Here on people with absent contract Il ity, you may have to adjust the different ranges. Thio look at the values even more so with that, with that second part of the, uh, looking at Paris, Tulsa's issues and impaired clearance, Um, does anybody have any other questions that may be from the first part of the webinar four or this this section? Sure, when a patient has hippo, contract, foul, esophagus and high i r p What is the diagnosis? Jackhammer or e g. J. Obstruction, hypo or hyper? I'm assuming they talking about hyper contract il ity within the D. C I or hypo like low correct low hyper hyper. Yeah. So it was the first place. So if it's hyper and what was the ire? Ph You know I missed that part. Sorry. Hyper contract Il ity and high I AARP. Yeah, so it would be one criteria will have to look at. Is this distal leighton? See Right here. So if this was above, um, the normal threshold for the catheter will say it's 30 and then you have hyper contract out here. We'll say it Z 8000 or so. It all depends if What? The dis Elaine C. Was it premature or was it within normal range? So if it was in normal range, it was seven centimeters for a second. This is hyper and then I r p was above the normal threshold would fall into outflow obstruction. Let's say this was hyper um this right here was now above stable. Say it's 30 and but it was premature is less than 4.5 centimeters per second. It would be into the actual Asia subject category. What is the younger age that on esophageal Manama tree can safely be performed in Children? And is there a specific to for an infant? Good question. I think the youngest I have ever done Asafa Geo Manama tree on a, uh, individual was four years of age, um, and non sedated. And they went through the whole sequence. Obviously we use it, but many different techniques and the major techniques be an ice age having them watch ice age on a TV. But we were able to do that. There are different size catheters, um, French size catheters from pediatric to adult, but outside of very, very anybody under the age of two. You know, we we just used the adult one on kids above the age of two. But there's different sizes, um, catheters you can try out, but that our experience in a couple places I've been we just used the adult size, um, anybody above the age of two. But I know there's some places also, you know, kids have a little bit trouble getting and even at the age of four, and they know places have placed it through endoscopy, then did the test after coming to recovery. But you probably still need some kind of, uh, something to keep their minds off, Not swallowing continuously or wanting the catheter taken out is our difference between Children's and adults regarding the normal values of D. C. Ideal. Oh, yeah, U s pressures and so forth. That's a great question. Um, I know there's several places working on that, but the Chicago classifications was employed on, um, adults. So, um, currently, I would say, if you're doing in my kids, that you would take to Chicago values and with a little bit of grain assault on do use them or as a guide, then as an algorithm. But either way, if they have swallow depictions that look like Eckel Asia images, regardless of these values over here, you could qualitatively call them that, um, even within normal type of metrics. So I would use the Chicago as a guide. But those numbers in the in the construction of the Chicago classification was done in the adult population. Last question. I wonder, how do you analyze a study where a patient with Eckel Asia has a and it has the I R P and the I. R P is apparently high during all the 10 swallowed and there is no Paris also at all And what would? But when you acquire the vertical swallow, the i. R. P is normal. Yeah, great question. Great question. So going back to our product, you know, the entire protocol those provocative ones. Um, I'm a big proponent on performing a lot of the provocative ones throughout the entire test. Um, in Eckel Asia, I think that's probably a little bit that that's probably a little less common that it normalizes out. So, um, and those you definitely would have to score as, um, Ankle Asia in the supine position, employing the Chicago classification. Conversely, with the upright positions, the AARP normal doubt. And if it was like no swallow vigor in here, it's still had absent contract contract il ity, so you would probably need some type of another test to adjudicate that probably in the barium swallow, the Asafa Graham would probably the test of choice. Um, but we do a lot, especially in outflow obstruction you Often you'll get outflow obstruction in the supine position, but when you bring them back up there. You know, there's been different type of percentages out there, um, but pretty significant ranges of percentages that the swallow becomes normal, mostly because the IRP becomes below the normal threshold or whatever catheter you're using. So again, you probably would need to use another test to adjudicate. That finding was the supine correct. It was the upright correct for that particular Chicago, um, where they fell in the Chicago classifications. But really good question. And that's why I'm a big proponent on all those provocative swallows. All right, let's move on to the next one. And great questions definitely keep them coming. Um, so that's where we're at before now. We're gonna look at minor disorders of Paracelsus and impaired clearance. This category right here more often than not will be if you take if you take a pie. And this is gonna be the primarily in my experience. Uh, primary piece of the pie. What your tests are gonna fall into is this category right here. So the first thing we wanna look at is basically we're gonna look at an effective ineffectiveness. Ovidio motility, I am is really what most people will call it as this is greater than 50% are ineffective swallows. So then, if you look down here, um, compared to the normal, they were effective swallows. So, um, this is gonna be the difference between the two and again. In the range is gonna be between 104 150 then fragmented Paracelsus, where the frag they're it's they're not ineffective. But there's gonna be these breaks of five centimeters are greater. So again, if you good way to this. Categorize your studies and this is where you can create different type of study tags, especially for research Institutions really find studies quickly, but we're gonna open up the I am one again. The resting has already been done. The first two are gonna be what we're gonna We're gonna turn off this pressure impedance contour. We only wanna look at the pressure contour again just by hovering over. We'll tell you what exactly it is. Um okay, so we're gonna walk through the swallow, and here we go over and first check. Let's check the IRA P first on this one. Is it normal or abnormal? It falls within the normal range of this catheter. So we're gonna check that off. So it's normal. I r p what about this late and see here is the late see? Normal or abnormal? Yep. The late C is normal. It's created in four centimeters per second. What about the D. C I? What about the vigor? The bigger is a little bit in effect again. It's above 100. We need at least 100 millimeters of mercury pressure to categorized as real physiological pressure, but it's lower than 4. 50. So this is gonna be this in this ineffective category than ineffective SAPA. Geo motility. Studies have shown that this could also contribute to reflect so as you bring them, um, after you walk through these and if you see a lot of these swallows, don't be surprised is that you don't have a US break right here, but then you'll start to have the Elliott start to relax. You'll start to see this, especially if you have this on. You'll start to see this purple. You kind of come up, creep up, creep up. Then you may have another secondary Paracelsus contraction without the U. S opening and pushing that down. That's what reflux started events starting to occur. Eso often in these studies, you'll see what you see These quite a bit. All right, let's go. Go on to a second US While we look at this exact same thing, let's check out Desire P normal. Dire. PIF is falls below the normal range. What about the latent? See, Leighton See, is normal. It's above 4.5 centimeters a second. What about the D. C I. It's again between 104 150. So we're going to consider that week are ineffective. So these are the type of swallow images you see If you were if you have greater than five or 10 or 50% of the swallows that you acquired than this would fall into that ineffective esophageal motility. And often if you turn on here that these type of swallows um, this one did have an entry and exit entry and exit. But these swallows right here can have impaired clearance. Um, often because there's not enough vigor to kind of push this. The bowl is down through the bottom of the esophagus and into the empty and phase of the into the stomach. So the next one is right here. We're going to see this. We're gonna look at a fragmented one. You see this big break that the current here, remember, the if you click down here, the white shows up here that the break right here is greater than five centimeters. So this is Ah, huge, fragmented break right here. Sometimes the fragment will be happening down in this range right here. Um and then eso The break doesn't have to be some way up up in the approximately or top part of the esophagus. It could happen anywhere within the pair of salsas itself. So when you're looking at these, your eyeballs will get better at seeing these big breaks. If it looks like five centimeters, it doesn't look like five centimeters. But if it's you can kind of you can you can right click. And you can add different different breaks in here to see if it's, uh, if this was missing, you could see if it was five centimeters or not in the software will calculate that for you. Um, that's what we have so far for this section. Doesn't even have any questions on this section is I want to go back to us. Something that happened in a previous section that often occurs with someone with a very long Asafa Ghous body. All right, I have a few questions regarding positioning. Um, what if people with swallowing issues have a more difficult time laying flat, uh, to swallow, And instead of doing sitting and supine position swallows, why not do all this follows at a 45 degree posture? Mhm. So regardless, if someone has a swallowing issue, they're gonna have challenged swallowing whatever position you put them into. So I don't think there's a difference position in the sense of the If they have a true trouble swallowing it kind of falls into one of the higher categories in the Chicago classification, the position changed. I don't think will be that big of a difference. Now, the type of you know, uh, type of thing you introduced to them either viscosity or fluid probably will have a greater impact. Their challenge of swallowing that, uh, that that type of ah intervention or that that type of bolas, um, that was the second part of the questions. You know, um, it's sort of doing sitting in supine position swallows. Why not just do all the walls at 45 degrees? Yeah. Sorry about that. Um, it's a good question. Um, it was just something that Chicago employed the supine position mostly to take away gravity. Um, that was the big reason. You just want to see what your body would have to do if you had to have your own vigor. Thio, Swallow that. Bullets down now, saying that I would do say I do employ a little bit of a deviation and in in the angle they swallow at maybe not 45 degrees, but definitely in that 25 30 if they've had a previous neck or back surgery, are often often people who just had recent hip surgery. Sometimes it's very hard for these people to lie completely flat. But also, when you do put someone in a flat position, you want to make sure that they have some small type of pillow O. R. A towel road rolled up or a blanket rolled up because sometimes these gurneys, if you put them without a pillow, they could get into a trend Lindbergh position, so that will also cause a lot of double swallowing a lot of nasal drainage, but you want to keep them, you know, 1, 80 or a little bit higher than that. Thio decreased impact of all the devil swallows because just the physician itself I have one last question. It's a It's a contraction that has more than one parasol tick break. How can you measure the two breaks or which one do you select to measure the parasol tick, break the proximal or the middle if you see the break in the middle? Good question. The first thing I would look at before I even measured the brakes was I would measure the D. C I. Is it Is it even enough bigger to fall into a week? Um, a weak category compared to basically just being trivial enough that Teoh measure it all like less than 100. After that, you can You could put this for a here, and then you could measure that that one. So the pressure break was 5.6 centimeters. And if you delete that right, you delete that, then if you're coming down here on the right click again, put up here outside the box and right click. You can add break and you can move that down into the range in the bottom. And then you could, you know, assess your break at that point, looking at the pressure break over here. So that would be one way to do it, but more often. Now, if you have huge breaks at the bottom here and it's greater than five centimeters and have a little bit of pressure here, I would first encourage you to look at the D C I before you went on to measuring the brakes itself. Good question, though. I'm gonna get out of here for one second and we look at a height, a hernia one. But I want to go back before our time is up. Often we talked about it back in Webinar, I think to if I'm not mistaking about long esophagus is and what that may look like on a swallow. So this is probably what comes up, I think what challenges most people of you know, traversing the E g. J. Is these hydro hernias. So, um, remember, from Webinar one, we talked about E g j morphology. You know, type one type two, then the type threes, and as you see that the L E s is up here, but they die for romantic pinches. Um, centimeters below sometimes is even greater than this looks. Looks like about two, maybe two, maybe three centimeters at some point break. So this in between here is high to sack. So this Catholic replacement, um right here You see, we didn't even get a member of the month. We always try to get least three centimeters into the gastric region, but were unable to do that because of the probably the hernia. Per said So you can use the height of sack as a as a gastric baseline if you needed here also. But you can still acquire the swallows even if you didn't get through the hernia because you can still you can still evaluate pair of stall sis, you can kind of get a good idea of the IRP relaxation because I really based on the gastric baseline, you could assess the vigor you can assess the district Leighton, see, So there's still stuff you can collect, so I wouldn't I wouldn't abort the test just because you didn't get through. Especially at large Heidel hernias. Um, you may wanna have to straighten the catheter out a little bit because especially if the catheter starts to curl a little bit in the height of Sacher here they tend to be gagging a little bit. So you may have to just a couple centimeters, but you could still move through the test, um, move through the test and collect some data to get a good evaluation. But you'd have toe use Chicago as a little bit of a grain of salt because we didn't get into the into the gastric region here again, Most of these the D. C. I is within the normal range. The dis awaits. He's tends to be normal. And I, r p, you know, is gonna be within the normal range offensive a week. But what ends up happening, be careful. When the bullets is coming down, it kind of sits in the sack. Then you'll get a huge reflex often. Then it will go back down. So you have this kind of cyclical region that's occurring throughout these swallows, and we could just check if this bowl is clear. Yeah, this one cleared right here and then went back. But often it will be back then it would go back down again because it's clear and a second time. Then we go back here, look at another image of the same thing, Um, of the high or hernia here, so s Oh, you know, I would still continue to collect this study, but just knowing that some of these are going to be more of a qualitative point, but you could get a good image of what potentially be contributing to the patient's symptoms. I'm gonna go back to one more. If anybody has any questions. I think it was in outflow obstruction, um, that we talked about a long esophagus and I believe webinar one or maybe two. Um, so someone didn't ask the question when we went through this. But you see how the you asked is like, cut in half, Basically up here, this person will say, um, just recently, within the last month, we did. We did a Asafa Geo Manama tree on someone that was 6 ft 11, so they had really long esophagus. So in this case, my suggestion is to place the catheter like you would normally would try to get three centimeters down here, even if you lose some of this us. Um Then what I would do is I Would we collect arresting pressure? We would keep the catheter here for about three swallows. Then after that, say we only had maybe one centimeter down in the stomach region. We would move the catheter back out where we had at least three centimeters down here, even if we had to forfeit some of the U. S. But least we had three. Sewall's within the U. S. Had been more down in this region right here. What? We could evaluate what was happening in the first South. Deals think they're in relation to their swallow. Does anybody have any questions? I know we're running out of time to make sure I answer anything that that someone may be more curious about. Okay, we have a number of questions when you get a butterfly way form on the tracing because of the catheter coil and can you still comment on the parasol? So no, it's a good question is good to recognize that it is coiling, but at that point, you just need thio, retract the catheter back out and try to do it again. Place the catheter again and butterflies. Often butterflies occur, especially if someone has a borderline or tighter. I r p that you're going a little bit too fast when you're placing the catheter. You kind of wanna pull that back out where you're at about 22 23 centimeters. Remember, from the Nair to basically that us is 18. So you're you're down in this region now. You don't want to take it through here, so there's more gagging, but you wanna go a little bit slower? Basically as a sip, you go as a sip. You go as a sip, you go instead of just kind of going quickly when they're just baby sipping. But you can't. You can't really analyze anything in a butterfly effect, right? There are some cases of actual Asia with normal IRP, mainly and type on ankle Asia. How can you established the differential diagnosis between absent contract il ity and type one ec? Alicia? Yeah. So, um, you're absolutely correct. You can have type. You can have normal IRA p and type one Eckel Asia or so what? What you would need then, is more likely another tested adjudicate that probably into their soft program. Um saw program type of thing to adjudicate those that finding. But if again you'd have toe, you'd have to definitely state what percentage is like 40% of the swallows met, uh, type one Eckel Asia and maybe the other ones met absent contract Taylor because of, um whatever the whatever the i r p level is. But another test would have to be adjudicated, um, to validate which one that that actually, um, actually was actually accurate. But often in all these type of swallow, all these types of studies thes swallows will deviate from swallow to swallow swallow. That's why it's really important, we said in a webinar one, you have to go through each individual, swallow and evaluate each individual swallow and Judi Kate each individual swallow so like outflow obstruction and type through type three. Sometimes during the 10 Swallows, this could be a collage of three, and sometimes it could be outflow obstruction. So that's a good question. But often you need another tested adjudicate that what are your thoughts on a distal break over five and a normal digger swallow? Well, if it's just one or so are just a couple of the 10 um, I don't think it really impacts that all it fall into that normal range anyways. But when you're getting greater than five of those, um, now 50% of your swallows are are fragmented and the lead with large breaks. I think there's some significance of that, Um, again, it probably those categories fall into reflux type of patients, but it just depends what the percentage of those swallows are we're talking about. What does that look like on the screen if you place the probe in the lungs in the lungs? Good question. Um, I have not seen that, um, often if you were going even if you were traversing into that region, um, I think there will be signs on the from the patient will let you know that you are not in the right region. Definitely would. Gasping for breath would be, uh, probably more laborious at that point, you know? So I would probably say there's mawr. That's a good question. 10,000 plus cities I've done. I've had that happen. But I guess it's probably the patient profile would let you know. You may not be in the wrong. Maybe in the incorrect region if someone has an image of that, I would love to see that, though. Uh huh. My institution seems to always comment on the resting US pressure, particularly when it's high. Is there any clinical significance in this? Good question. I think that is that is a beacon ing area research right now. But remember, from the webinar one and two when we look at the anatomy, if I turn my head this way or this way or this way or I'm going like this like I can impact the pressure of the catheter itself, s so it's really important to keep people, um, straight as possible. Um, is there issue if people maybe have crack and fair in jail dysplasia that I think there is some evidence for that or Globus that would be another area of someone had that as a primary complaint. There could be some evidence for that reasons for that. But I think there is some you should definitely documented on all studies. But whoever the Allied Health person is is performing it. Make sure they, their head, the patient's head, is the straightest possible, not moving and creating the variability in itself just by positioning. What are your thoughts on using a rapid drink challenge to differentiate between taipan Eckel Asian absent contract il ity in a patient with a high, normal IRP. I'm totally in favor of that. We do that. We do the rapid drink to MLS every basically two seconds. Soon you see See the US break drinks while drinks while drinks while drinks while drinks while five of those. Then we count from 0 to 30. Don't have the patient, uh, swallow. Let the glut of inhibition happened and excited. Torrey response. Come back. Um, you could definitely do that. I would definitely encourage that. Um um, that would give you some evidence of both the European and excited Torrey response. I would I would definitely encourage that. That's our practice here on everybody We do rapid drink challenge. We do that whole protocol that we've been showing over the first four webinars, if you have below normal distillation late Quincy and high D. C I with normal irp would you call the D. E s with jackhammer? I'm right. Normal. I r p What you say normal distillates. Normal distill agency high D c I normal irp. Would you call the D C. D s with jackhammer. Well, remember they had to meet a certain percentage. So if one swallow had it, you know, it fell in all the other swallows fell normal would be normal. So it is safe is D s. Um, we kind of rural DCs out because it's a normal distal agency. Um, the jackhammer of his normal distal agency. And in the normal I R p and the hyper contracted the d c. I. Then it was over 2020% of the swallows you collected. Um, then it would fall into that jackhammer. You know, it had to be greater than 8000 millimeters. Murkier pressure percent, second per centimeters. So if that met all those criteria and it was greater than 20% of all the swallows, you collected it. Yeah, into the jackhammer. All right, Jason, Last question. What risks do you discuss with the patient prior to starting Manama tree? Good question. We have specific consent forms that we've used over the years. So the risk that we for things that we always describe them is that, you know, obviously we're putting something in someone's body so it could potentially be perforation, bleeding discomfort and the one thing we've added over the years, um, is sore throat because often people will leave and they're sort their throats a little sore. And that's the one we just experienced that people often expressed. So we end up adding that to the risk. But those who are the four that we we present thio each patient before we perform the test. Great. Well, thank you, Jason. This concludes our webinar advanced editing techniques. If you missed any of the webinars in the syriza, recordings will be uploaded this week to diverse the Czech University for you to access. Please, please stay tuned for new webinars as we explore other motility topics in the future, upcoming webinars will be posted on diverse attack healthcare dot com and watch your inbox as schedules and ties will be emailed to those who are registered with diverse a tech university. Thank you and good night. Yes, Created by
