Chicago Classifications. Quick Start Guide for Suite P

Transcription

1 Chicago Classifications Quick Start Guide for Suite P

2 Opening the Study - Isocontour Isocontour Isocontour lines encompass all pressure values at the indicated pressure settings. These are required for marking Chicago Calculations or measurements. Isocontour lines will be displayed automatically when the study is opened in analysis. The software has two isocontour line levels. The black isocontour line value (30 mmhg) is used for marking CFV and Distal Latency. The gray isocontour line value (20 mmhg) is used for Peristaltic Break and DCI. These values can be set to user preference by dragging the triangles to the desired position on the scale. Drag the triangles to change the isocontour line levels. Figure 1: Pressure ClouseVIEW with Isocontour line levels at 30 mmhg (black) and 20 mmhg (gray) 2

3 Muscle Segments and Phases Of Peristalsis All of the Chicago Analysis Marks are made in the smooth muscle segment of the esophagus. Striated muscle approximately 1-2 cm below the UES Smooth muscle below the proximal pressure trough including the LES A swallow contraction sequence is divided into two phases in the smooth muscle. The first is the rapid peristaltic phase from just below the proximal pressure trough to the distal esophagus. In normal peristalsis there is a marked deceleration in the slower esophageal emptying phase. This landmark is known as the Contractile Deceleration Point (CDP) and is the demarcation between the tubular esophagus and the phrenic ampulla. The CDP is used for marking as a data point for Contractile Front Velocity (CFV) and Distal Latency (DL) (the two measurements that use the 30 mmhg isocontour). Rapid peristaltic phase CDP Esophageal emptying phase 3

4 Create a Temperature Compensation For accurate Chicago Calculations, temperature compensation at body temperature under atmospheric pressure must be performed prior to any editing. The following BioVIEW Analysis steps are used to create temperature compensation: Load an HRiM patient into the Analysis software. Turn on ClouseVIEW. Set the Time Range to 1 minute. Scroll to the end of the procedure. Click on the screen so that a flashing reference line will appear on the screen at the point IMMEDIATELY (within a few seconds) following extubation. Click on the Edit menu. Click on Create Compensation. The contour colors will redraw using the adjusted data values. When the patient file is saved, the Temperature Compensation setting will also be saved and need not be set again for the given patient. Position the Flashing Cursor IMMEDIATELY following extubation when creating a Temperature Compensation Figure 2: Temperature Compensation immediately after the extubation point 4

5 Chicago Classification Analysis Display After completing the temperature compensation, move back to the first liquid swallow. In the contour view, without the waveform overlay, click on the Analysis Tool icon. A measurement box will appear which was created during acquisition. A single left click in the measurement will activate this box (it will now have a dashed border). The Chicago analysis marks will be displayed and the relevant values will appear in the data box. The Chicago analysis marks cannot be moved beyond the borders of the defined swallow measurement box. If more space is needed for the Chicago analysis marks, adjust the swallow measurement box margins first, then adjust the Chicago marks as needed. Measurement box created during acquisition now active Chicago analysis marks are present and can be adjusted if needed 5

6 Integrated Relaxation Pressure (IRP) Integrated Relaxation Pressure (IRP) is a measure of the extent of relaxation of the lower esophageal sphincter relative to a gastric baseline beneath the same swallow. The IRP, measured in mmhg, is a box starting at the onset of the swallow (start of relaxation of the UES) a little above the proximal edge of the LES. It is drawn to the right until the distal end of the contraction wave reaches the LES or approximately 10 seconds if no contraction is seen. It is also drawn down to envelope the thickness of the LES. The values here are compared to a quiet gastric baseline below the swallow. The IRP box must be at least 4 seconds wide as the 4 seconds of maximum relaxation are measured after the swallow is initiated. The cursor changes to a double white arrow to adjust the IRP box vertically or horizontally if needed 6

7 Distal Contractile Integral (DCI) The Distal Contractile Integral (DCI) is a measure of contractile vigor. The DCI is a box circumscribing the amplitude, duration and length of the smooth muscle swallow propagation as a 3D topographic value. The value considers all data within the 20 mmhg isocontour. It is measured in mmhg x sec x cm. The cursor will change to a double white arrow to adjust the DCI box vertically or horizontally if needed 7

8 Distal Latency (DL) Distal Latency (DL) is a measure of peristaltic timing. The DL is the time, in seconds, from the onset of swallow (start of UES relaxation) to the CDP using the 30 mmhg isocontour. The cursor will change to a plus sign to adjust either end of the DL line if needed 8

9 Peristaltic Break (PB) Peristaltic Break (PB) is a measure of peristaltic integrity. The PB, measured in centimeters, is a break in the 20 mmhg isocontour. In a given swallow there may be no break in integrity or there may be a break in the proximal, mid or distal esophagus. If there is more than one break in a single swallow, measure the longest break to best represent fragmentation of the contraction. The cursor will change to a plus sign to adjust either end of the PB line if needed 9

10 Contractile Front Velocity (CFV) Contractile Front Velocity (CFV) is a measure of velocity in the peristaltic phase of the smooth muscle contraction. Proximal and distal points on the front (left) edge of the 30 mmhg isocontour along a large intact segment of the smooth muscle are connected with a tangent. The slope of this tangent is the CFV. The CFV, measured in cm/sec, runs from just below the proximal pressure trough (or below the striated muscle segment if no pressure trough is seen) to the CDP. The cursor will change to a white quad arrow when placed in the lower right quadrant of the circle at either end of the tangent Left click and drag to adjust the CFV line if needed 10

11 Adding Chicago Calculation Data to the Report After all desired Chicago Calculation measurements have been reviewed; select the Create Report menu item from the Report menu. The Procedure Report dialog will appear. Click Options. Click Lower ESOB tab. Check Show Chicago Calc Table option.* Click OK. Click OK again. The report will be generated. * This step only needs to be done the first time you add these values to a report. Once this option is selected, it will be included in each future report. 11

12 Adding Chicago Calc Data to the Report (continued) A table will appear in the report that displays the Chicago Calculation data. The data are organized in tables based on the swallow type. NOTE: In order to see Chicago Calculation data for swallows acquired with viscous material, all viscous swallows must have a swallow-relax measurement. For more information on use of the Chicago Calculation in the Chicago Classifications please see the following reference: Chicago Classification Criteria of Esophageal Motility Disorders Defined in High Resolution Esophageal Pressure Topography; A. J., Bredenoord, M. Fox, P.J. Kahrilas, J.E. Paldolfino, W. Schwizer, A. J. P. M. Smout, The International High Resolution Manometry Working Group; Neurogastroenterology & Motility 2012 March; Volume 24 Issue s1:

13 Editing Hints When Using Suite P Conventional waveform edits (moving of baselines and re-analyzing all measurements) should be done before editing the Chicago analysis marks. This way you won t inadvertently re-analyze (revert to computer analysis) the Chicago analysis marks you have already adjusted. Re-analyzing a swallow in the Chicago view will re-analyze the same swallow in the conventional (waveform) view and visa versa. The Chicago analysis marks cannot be moved beyond the borders of the swallow measurement. If the measurement box needs to be adjusted, do this before moving the Chicago marks. Moving the edge of a swallow measurement box re-analyzes this swallow in both the Chicago view and the waveform view you may need to re-edit the waveform view for this swallow. If you move the lower circle of the CFV, the right edge of the DL will adjust with it because they both share the CDP. If you move the upper margin of the IRP box, the lower margin of the DCI box will adjust with it because they both share the proximal edge of the LES. To improve the view of the swallows when reviewing the Chicago analysis marks, left click on the threshold at the top of the pressure section and drag it up to hide the Impedance section. Left click and drag threshold up past Impedance section 13

14 Editing Hints When Using Suite P (continued) To add a Chicago analysis mark, right click in the swallow measurement and select the mark to be added. If you will be adding a DL, first set the CFV at the CDP and the onset of the IRP at the onset of swallow, then right click to add the DL. The Distal Latency will populate into the correct spot. When adding a CFV, DL or PB line, it doesn t matter which side is up, down, right or left. The values are the same no matter the orientation. To delete a Chicago analysis mark hover the arrow over the border of the box (for DCI or IRP) or on any part of the line (for CFV, DL or PB), right click and Delete Analysis Mark. IMPORTANT ORDER OF OPERATION: For best results: 1. Perform temperature compensation. 2. Complete all conventional (waveform) editing. 3. Edit Chicago analysis marks if needed (contour view). 14

15 Using Suite P To Analyze A Study Acquired With An Older Software Version If using Suite P to analyze a study acquired using an older software version, there is an extra set-up step to prepare the measurement boxes for Chicago analysis. The measurement boxes created by prior software versions are not created over enough channels for proper Chicago analysis. After completing the temperature compensation and BEFORE DOING ANY CONVENTIONAL (WAVEFORM) EDITING, open the analysis tool at the first swallow, double left click inside this measurement box (1). A Change Measurement box will open. On the right side of this box, check every channel (do not leave any channels unchecked) (2). Next, change the name of any one channel (3). This can be done by left clicking on the name of one channel. A drop down arrow will show for this channel allowing you to re-name it. Usually, it works best to change the upper-most channel from UES to Pharynx. Once all channels are checked and one is re-named, click OK to close the Change Measurement box. By checking all the channels, the swallow measurement box will lengthen to cover all the pressure channels of all of the swallow measurements. 15

16 Using Suite P To Analyze A Study Acquired With An Older Software Version (continued) When the above message appears, click Yes. IMPORTANT ORDER OF OPERATION For best results: 1. Perform temperature compensation. 2. Check all channels/re-name one/accept for all swallows. 3. Complete all conventional (waveform) editing. 4. Edit Chicago analysis marks if needed (contour view). Sandhill Scientific, Inc 9150 Commerce Center Circle, #500 Highlands Ranch, CO USA Fax: COPYRIGHT 2014 SANDHILL SCIENTIFIC PRINTED IN THE U.S.A. PM , Rev