High-resolution esophageal manometry in pediatrics: Effect of esophageal length on diagnostic measures

BACKGROUND: High-resolution esophageal manometry (HREM), derived esophageal pressure topography metrics (EPT), integrated relaxation pressure (IRP), and distal latency (DL) are influenced by age and size. Combined pressure and intraluminal impedance also allow derivation of metrics that define distension pressure and bolus flow timing. We prospectively investigated the effects of esophageal length on these metrics to determine whether adjustment strategies are required for children. METHODS: Fifty-five children (12.3 ± 4.5 years) referred for HREM, and 30 healthy adult volunteers (46.9 ± 3.8 years) were included. Studies were performed using the MMS system and a standardized protocol including 10 × 5 mL thin liquid bolus swallows (SBM kit, Trisco Foods) and analyzed via Swallow Gateway (www.swallowgateway.com). Esophageal distension pressures and swallow latencies were determined in addition to EGJ resting pressure and standard EPT metrics. Effects of esophageal length were examined using partial correlation, correcting for age. Adult-derived upper limits were adjusted for length using the slopes of the identified linear equations. KEY RESULTS: Mean esophageal length in children was 16.8 ± 2.8 cm and correlated significantly with age (r = 0.787, P = .000). Shorter length correlated with higher EGJ resting pressure and 4-s integrated relaxation pressures (IRP), distension pressures, and shorter contraction latencies. Ten patients had an IRP above the adult upper limit. Adjustment for esophageal length reduced the number of patients with elevated IRP to three. CONCLUSIONS & INFERENCES: We prospectively confirmed that certain EPT metrics, as well as potential useful adjunct pressure-impedance measures such as distension pressure, are substantially influenced by esophageal length and require adjusted diagnostic thresholds specifically for children.Maartje M. J. Singendonk, Lara F. Ferris, Lisa McCall, Grace Seiboth, Katie Lowe, David Moore, Paul Hammond, Richard Couper, Rammy Abu, Assi, Charles Cock, Marc A. Benninga, Michiel P. van Wijk, Taher I. Omar

Remifentanil alters sensory neuromodulation of swallowing in healthy volunteers: quantification by a novel pressure-impedance analysis

Exposure to remifentanil contributes to an increased risk of pulmonary aspiration, likely through reduced pharyngeal contractile vigor and diminished bolus propulsion during swallowing. We employed a novel high-resolution pressure-flow analysis to quantify the biomechanical changes across the upper esophageal sphincter (UES). Eleven healthy young (23.3 ± 3.1 yr old) participants (7 men and 4 women) received remifentanil via intravenous target-controlled infusion with an effect-site concentration of 3 ng/ml. Before and 30 min following commencement of remifentanil administration, participants performed ten 10-ml saline swallows while pharyngoesophageal manometry and electrical impedance data were recorded using a 4.2-mm-diameter catheter housing 36 circumferential pressure sensors. Remifentanil significantly shortened the duration of UES opening (P < 0.001) and increased residual UES pressure (P = 0.003). At the level of the hypopharynx, remifentanil significantly shortened the latency from maximum bolus distension to peak contraction (P = 0.004) and significantly increased intrabolus distension pressure (P = 0.024). Novel mechanical states analysis revealed that the latencies between the different phases of the stereotypical UES relaxation sequence were shortened by remifentanil. Reduced duration of bolus flow during shortened UES opening, in concert with increased hypopharyngeal distension pressures, is mechanically consistent with increased flow resistance due to a more rapid bolus flow rate. These biomechanical changes are congruent with modification of the physiological neuroregulatory mechanism governing accommodation to bolus volume.S. H. Doeltgen, T. I. Omari and J. Savilamp

Disordered swallowing associated with prolonged oral endotracheal intubation in critical illness

Abstract not availableMistyka S. Schar, Taher I. Omari, Robert J. Fraser, Andrew D. Bersten and Shailesh Bihar

Pharyngo-Esophageal Modulatory Swallow Responses to Bolus Volume and Viscosity Across Time

OBJECTIVES/HYPOTHESIS: Modulation of the pharyngeal swallow to bolus volume and viscosity is important for safe swallowing and is commonly studied using high-resolution pharyngeal manometry (HRPM). Use of unidirectional pressure sensor technology may, however, introduce variability in swallow measures and a fixed bolus administration protocol may induce time and order effects. We aimed to overcome these limitations and to investigate the effect of time by repeating randomized measurements using circumferential pressure sensor technology. STUDY DESIGN: Sub-set analysis of data from the placebo arm of a randomized, repeated measures trial. METHODS: HRPM with impedance was recorded using a solid-state catheter with 36 circumferential pressure sensors and 18 impedance segments straddling from hypopharynx to stomach. Testing included triplicates of 5, 10, and 20 ml thin liquid and 10 ml thick liquid boluses, the order of the thin liquid boluses was randomized. The swallow challenges were repeated approximately 10 minutes after finishing the baseline measurement. RESULTS: We included 19 healthy adults (10/9 male/female; age 24.5 ± 4.1 year). Intrabolus pressure, all upper esophageal sphincter (UES) opening and relaxation metrics, and flow timing metrics increased with larger volumes. A thicker viscosity decreased UES relaxation time, UES basal pressure, and flow timing metrics, whereas UES opening extent increased. Pre-swallow UES basal pressure and post-swallow UES contractile integral decreased over time. CONCLUSION: Using circumferential pressure sensor technology, the effects of volume and viscosity were largely consistent with previous reports. UES contractile pressures reduced over time. The growing body of literature offers a benchmark for recognizing aberrant pharyngo-esophageal motor responses. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:1817-1824, 2022

High-resolution impedance manometry parameters in the evaluation of esophageal function of non-obstructive dysphagia patients

BACKGROUND:High-resolution impedance manometry (HRIM) allows evaluation of esophageal bolus retention, flow, and pressurization. We explored novel HRIM measures and assessed their temporal relationship to dysphagia symptoms for boluses of different volume and consistency in non-obstructive dysphagia (NOD) patients. METHODS:Thirty-three NOD patients (n = 19 minor or no disorder of peristalsis ("Normal") and n = 14 esophagogastric junction outflow obstruction ("EGJOO")) were evaluated with HRIM. Patients were administered 5 and 10 mL liquid, semisolid, and 2 and 4 cm solid boluses and indicated bolus perception during individual swallows using a 5-point Likert scale. HRIM was analyzed to assess Chicago Classification and pressure flow metrics, esophageal impedance integral (EII) ratio, and bolus flow time (BFT). KEY RESULTS:Overall, bolus perception increased with increasing bolus consistency (P < 0.001), but did not differ significantly between EGJOO and Normal patients. EGJOO patients had higher IRP4, higher levels of bolus residual (ie, EII ratio and IR), and restricted esophageal emptying. The results for linking semisolid bolus perception to semisolid-derived measures revealed more biomechanically plausible and consistent patterns when compared to those derived for liquid boluses. In Normal patients, perception of boluses of heavier viscosity was related to higher bolus flow resistance during transport, whilst in EGJOO, perception was related to restriction of esophageal emptying. CONCLUSION & INFERENCES:These novel pressure-impedance measures may aid in the evaluation of NOD patients by revealing abnormal motor patterns, which may explain symptom generation. Future studies are needed to evaluate which of these measures are worthy of calculation and to establish protocol settings that allow for their meaningful interpretation.Maartje J. Singendonk, Zhiyue Lin, Charlotte Scheerens, Jan Tack, Dustin A. Carlson, Taher I. Omari, John E. Pandolfino, Nathalie Romme

Behavior and gastroesophageal reflux in the premature neonate

International audienc