The Modified Barium Swallow Study: So much more than a pass/fail test
I would like to express my gratitude to Jo Puntil, MS, CCC-SLP, and Angela Menlove, MS, CCC-SLP, BCS-S. Their exceptional course on this subject served as the inspiration for this piece, and I am grateful for their review and approval of the final text.
Me: Hi doctor, I completed Mr. Hernandez’s modified barium swallow study (MBSS), and he presents with moderate oropharyngeal dysphagia characterized by poor bolus formation/control, posterior bolus loss, and gross aspiration before the swallow, with silent aspiration due to reduced airway sensitivity. There are a few things I’m going to try as compensatory strategies to protect his airway and improve his safety during meals.
Doctor: So… Did he pass?
Me: …
Spoiler alert: The MBSS is NOT a pass/fail test.
So what is it? The true purpose of an instrumental assessment is to evaluate the safety and efficiency of the swallow, focusing on the intricate motor and sensory physiology. We are looking for the why behind the problem, not just the what.
So what can we do to make other disciplines realize that there is so much more to the MBSS than just a pass-or-fail verdict? We don’t fail our patients after their chest X-rays or after the CT scans and MRIs. So why after an MBSS?
As we evolve as a field, we’re realizing that standardizing this complex test might be the answer.
Standardizing Diets
The first thing we need to standardize is the diet consistency recommended for our patients. Go to one hospital, and the nectar-thick liquid looks one way. Drive up the road to another, and it could be a completely different consistency, regardless of whether they’re both called nectar thick. Think that’s crazy? Turns out you can play the same game within the same hospital. Yup, your nectar thick in one fridge could be an entirely different consistency from the nectar thick container in the other fridge down the hallway.
But why?
Liquid viscosity isn't a simple, linear thing. It’s a shape-shifter. A liquid's consistency changes with its temperature, how much it is compressed, and even how long it sits after mixing with salivary amylase (the enzymes in your spit!).
IDDSI has standardized our consistencies so that all SLPs, kitchens, and the rest of the medical team are speaking the same language across disciplines, facilities, and even countries. But, as with all positive changes in healthcare, it takes time, and many facilities still haven’t adopted IDDSI.
And Barium Too
To see the swallow on an X-ray, SLPs use barium sulfate products. Otherwise, there’s no shadow. But if you aren't using a standardized barium specifically made for SLPs (Varibar), you may see dysphagia where there isn’t any. Other GI bariums are intentionally designed to coat the throat and stomach, causing residue. That’s what gastroenterologists and radiologists want from these bariums: A coating…
But a coating of barium residue on a modified barium swallow study is a sign of a functional deficit and may lead to misdiagnoses, mistreatment, and an array of unintended and easily avoidable negative consequences. It’s the opposite of rose-colored glasses. It’s barium-coated-colored glasses.
Can you imagine being told you had a disorder when it was just the clinician’s eyes playing tricks on them?
To Aspirate or Not to Aspirate. Is that really the only question?
The MBSS isn’t pass-or-fail, and it’s not simply a matter of determining whether a patient aspirated. First of all, Dr. Langmore already taught us that aspiration is necessary, but not sufficient, for aspiration pneumonia. In other words, even if a patient was aspirating, that’s far from the end of the story. So why stare at a shadow and look to see which direction it goes on a screen? Household animals have been trained to do far more impressive things.
We focus so much on aspiration because we’ve learned that any liquid entering the airway is a crisis. Even laryngeal penetration above the level of the vocal folds. But the truth is, penetration is actually normal in healthy people, and thickening a patient's liquids because of it isn’t just inappropriate, it’s dangerous, as thickened liquids can lead to dehydration, poor quality of life, and even an increased risk of aspiration pneumonia in some circumstances.
Case Study: A Tale of Two Hospitals
“Uncontrolled variation is the enemy of quality” - W. Edwards Deming
Meet Alan, who is the first person ever to participate in a one-person randomized controlled trial. He can do this because he lives in both parallels of the multiverse.
Control Group: Alan has a stroke and goes to a small community hospital. He is complaining of food sticking in his throat. The SLP there hasn't been given a standardized protocol. They do the same thing they’ve always done, not thinking twice about it. They mix regular GI barium powder with the PO trials. During the test, the SLP only records at a low frame rate and doesn't check Alan's esophagus. Because the GI barium coats his throat, the SLP notes "severe residue" and makes him NPO.
The Experimental Group: Alan has a stroke and goes to a small community hospital. He is complaining of food sticking in his throat. This facility uses Varibar, ensuring the liquid doesn't coat his throat and trick us into thinking there is weakness when there isn’t. The SLP follows a standardized protocol, evaluating ALL aspects of swallowing from the lips to the stomach entry. They use a standardized scoring system to evaluate his physiology. A functional oropharyngeal swallow is observed with adequate airway protection and oropharyngeal clearance. They notice mild deficits in esophageal motility, which improve with small bites, avoiding dry food, sitting upright, and taking deep breaths during the meal. Alan gets to safely drink regular water and eat real food again.
Medicare is Watching You
This kind of variation from hospital to hospital (and even SLP to SLP within the same facility) is exactly why the Centers for Medicare & Medicaid Services (CMS) is getting involved.
CMS has fundamentally changed how healthcare is funded, rewarding facilities for value and positive outcomes rather than just the volume of procedures they do. You wouldn’t pay a mechanic to fix your transmission if you got it back with the same broken transmission and a missing tire, would you?
CMS is specifically looking at SLP practices in radiology. Here are 4 red flags they‘re looking for:
Using nonstandardized tests
Lacking reproducible results
Failing to communicate across the continuum of care
Missing a clear care plan based on physiology
So, what can you do?
The Solution: Superusers and Standardization
Standardize as much as possible. Start small and build from there. 4 areas to focus on first:
Use Varibar, which is made specifically for modified barium swallow studies.
Use IDDSI to ensure the textures are what we think they are.
Increase imaging frame rates to 30 pulses per second. The screen shouldn’t look like your television from 1993, where the antenna needs to be adjusted for a clear image.
Use MBSImP or DIGEST to ensure the evaluation process can be objectively measured.
Some healthcare systems are training a tier of "superusers" who volunteer to receive intensive, specific training from Board-Certified Specialists in Swallowing (BCS-S). Once competent, these superusers take on the responsibility of mentoring, observing, and establishing the competency of all the other SLPs in the system. It doesn’t matter if you’ve been there for 10 days or 10 years… No one is "grandfathered in"—everyone must prove they can meet the standard.
By focusing on standardized supplies, procedures, and continuous peer-to-peer mentoring, you can ensure that no matter who a patient is or where they are, they receive the same high-quality, evidence-based care.
Interested in learning more? Check out this course on Medbridge and use code “DUDE” at checkout for a nice little discount.
Standardizing the Modified Barium Swallow Across a Healthcare System
