Preliminary Investigation of the Effect of Pulse Rate on Judgments of Swallowing Impairment and Treatment Recommendations

Abstract

Reducing fluoroscopic pulse rate, a method used to reduce radiation exposure from Modified Barium Swallow Studies (MBSSs), decreases the number of images available from which to judge swallowing impairment. It is necessary to understand the impact of pulse rate reduction on judgments of swallowing impairment and, consequentially, treatment recommendations. This preliminary study explored differences in standardized MBSS measurements (Modified Barium Swallow Impairment Profile (MBSImP™©) and Penetration Aspiration Scale (PAS) scores) between two pulse rates: 30 and simulated 15 pulses per second (pps). Two reliable speech-language pathologists (SLPs) scored all 5 MBSSs. Five SLPs reported treatment recommendations based on those scores. Differences in judgments of swallowing impairment were found between 30 and simulated 15pps in all 5 MBSSs. These differences were in six physiological swallowing components: initiation of pharyngeal swallow, anterior hyoid excursion, epiglottic movement, pharyngeal contraction, pharyngeal-esophageal segment opening and tongue base retraction. Differences in treatment recommendations were found between 30 and simulated 15pps in all 5 MBSSs. These findings suggest that there are differences in both judgment of swallowing impairment and treatment recommendations when pulse rates are reduced from 30pps to 15pps to minimize radiation exposure.

Fluoroscopic Evaluation of Oropharyngeal Dysphagia: Anatomic, Technical, and Common Etiologic Factors

“…A high image acquisition rate (using either continuous or high frequency pulsed fluoroscopy) is recommended to ensure that brief or subtle findings such as penetration or tongue pumping are not overlooked. It is reported that evidence of aspiration is missed more often when only 15 images per second are viewed (vs. 30 images per second) [36]. Furthermore, to counter the commonly-voiced opinion that radiation exposure may be reduced by using lower fluoroscopy pulse rates, it has been shown that overall procedure length is shorter, meaning that fewer swallows are required to obtain answers to clinical questions, when image acquisition rate is set at 30 images per second vs. 15 images per second [36].…”

“…It is reported that evidence of aspiration is missed more often when only 15 images per second are viewed (vs. 30 images per second) [36]. Furthermore, to counter the commonly-voiced opinion that radiation exposure may be reduced by using lower fluoroscopy pulse rates, it has been shown that overall procedure length is shorter, meaning that fewer swallows are required to obtain answers to clinical questions, when image acquisition rate is set at 30 images per second vs. 15 images per second [36]. Thus, adherence to the ALARA principle (i.e., as low as reasonably achievable) is best achieved by collecting 30 images per second and following a standardized protocol.…”

Expanding Instrumental Options for Dysphagia Diagnosis and Research: Ultrasound and Manometry

“…While a typical VFSS is recorded at a maximum of 30 frames per second [10], conventional pharyngeal manometry can provide temporal information in the millisecond range [74]. Therefore, conventional manometry can be paired with VFSS, termed manofluoroscopy, to directly visualize swallowing events time-locked with an analysis of temporal and amplitude pharyngeal pressure parameters.…”

“…Another limitation of VFSS is the need to balance the temporal resolution of a high screening rate with radiation safety issues inherent in increased exposure. Research has documented that a minimum sampling rate of 30 frames per second is required for the identification of key features of dysphagia [10]. However, even this may be inadequate for some pathophysiologic features.…”

Identification of Swallowing Tasks From a Modified Barium Swallow Study That Optimize the Detection of Physiological Impairment

“…Because standardized health care practices, including diagnostic procedures and interventions, have been shown to optimize patient safety and outcomes, attempts have been made to standardize the MBSS to facilitate transparency in data acquisition and reproducibility of diagnostic information across clinics and laboratories (Agency for Healthcare Research and Quality, 2003;Ciucci, Jones, Malandraki, & Hutcheson, 2016;Clave & Shaker, 2015). Doing so has allowed for the consistent identification of physiological impairment(s) and the development of treatment plans known to effect positive change in swallowing physiology (Jaffer, Ng, Au, & Steele, 2015;Logemann, 1987;Martin-Harris et al, 2008;Palmer, Kuhlemeier, Tippett, & Lynch, 1993).…”