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Modified Mondays: Look twice, report once

Pro tip: Swallowing is FAST. The whole process starts and finishes in a matter of seconds for most people, so it can be easy for even the most watchful of clinicians to miss things during the study. This is why most educators in instrumental assessment advocate for reviewing the images every single time-even if it looks like a perfectly normal study. (How do we know it’s normal if we don’t verify?) Just like a carpenter completing a woodwork project, better to check twice before making important decisions (“Measure twice, cut once” as the saying goes).

This study from our Pittsburgh team highlights why reviewing the study-every time-can be so very important. The patient had a history of unilateral vocal fold paralysis following extended intubation (due to complications of COVID-19), and some recent increased lung congestion after resuming PO in acute care (no instrumental completed), then being discharged to the SNF for rehab. During the completion of our protocol on the MBS, the swallow appeared pretty functional. Upon review, however, we could see that the timing of airway closure, with some probable help from the vocal fold paralysis, was allowing some trace aspiration with no response from the patient. (Aspiration with vocal fold paralysis is especially sneaky-note how it just slides down the posterior wall of the trachea here.)

This study is also another great opportunity to point out the need for at least 30 pps on your MBS studies. The aspiration here happened in just about .08 seconds, so there is a decent chance that even at 15 pps it wouldn’t have appeared. See below for some references on this topic.

Completing an instrumental is only useful if we gather accurate data… just like a beautiful new cornice handmade by your handy husband is only useful if it’s long enough for the intended window (possibly true story).

Best Practices in Modified Barium Swallow Studies - PMC (

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

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