4 APPLICATIONS IN CONTRAST IMAGING D ysphagia (difficulty swallowing) is a serious physiologic disorder seen in individuals of all ages but is relatively common in the elderly and in those with a number of conditions, including stroke, oropharyngeal and esophageal cancers and cancer treat- ments, certain neurologic diseases, and gastroesophageal reflux disease. 1 In pediatric populations, dysphagia is seen most often in those born prema- turely and/or with cardiac, pulmonary, craniofacial, airway, and neurologic impairment, as well as those with de- velopmental disorders. 2-6 Importantly, published prevalence rates for dyspha- gia are likely a gross underestimation, as the primary diagnosis of a patient with dysphagia is often the underlying condition (e.g., stroke), not the dys- phagia itself. 7 The burden of dysphagia includes association with significantly longer lengths of hospital stay, higher likelihood of discharge to a post-acute care facility, and greater odds of inpa- tient mortality vs comparable inpa- tients without dysphagia. 8 The modified barium swallow study (MBSS), also known as the video- fluoroscopic swallowing study (VFSS), uses barium sulfate radiographic con- trast media of different viscosities to assess swallowing physiology and di- agnose dysphagia. Research shows that standardization of the procedure and its materials optimizes the ability to capture swallowing impairment 9 and minimizes radiation exposure, 10 lead- ing to safer videofluoroscopy examina- tions. There are three important as- pects of MBSS standardization, which relate to (1) the contrast media, (2) the examination protocol, and (3) the match between diagnostic stimuli and dietary consistencies, for people with dysphagia. Varibar ® (Bracco Diagnos- tics; Monroe Township, NJ) is a series of barium sulfate-containing prepara- tions available in 5 standard consisten- cies: Thin Liquid, Nectar, Thin Honey, Honey, and Pudding. 11-15 The Modified Barium Swallow Impairment Profile (MBSImP) is a standard protocol and rating system used to accurately and consistently quantify and communicate MBSS findings in adult populations. 16,17 The International Dysphagia Diet Stan- dardisation Initiative (IDDSI) is a frame- work of new, standardized terminology and testing methods to describe food textures and drink thicknesses, with the goal of developing global standard- ized terminology and descriptors for dysphagia diets. 18 The objective of this article is to assist clinicians and other healthcare providers tasked with diagnosing and managing the patient with dysphagia in understanding the relationships between Varibar, the MBSImP, and the IDDSI framework, and how to apply them in clinical practice. In addition, this article seeks to address consid- erations specific to pediatric patients and practice-related policies and pro- cedures. Evaluation of Dysphagia Using the MBSS, Barium Sulfate, and the MBSImP The MBSS is a barium sulfate-en- hanced fluoroscopic motion study typically performed by a speech-lan- guage pathologist (SLP) together with a radiologist, assisted by a radiologic technologist, to evaluate anatomy and swallowing physiology simultaneously in real time. 19 The goals of the MBSS are: (1) to identify and distinguish the presence, type, and severity of physi- ologic swallowing impairment; (2) to determine the safety and efficiency of oral intake; (3) to determine the impact and appropriateness of selected inter- ventions (postures, maneuvers, bolus variables) on swallowing physiology, airway protection, and efficiency in real time; and (4) in collaboration with the treating physician and interdisciplinary team, to develop intake and diet tex- ture/nutritional management plans. 19 Identification of dysphagia pathophysi- ology also guides selection of appropri- ate rehabilitative treatment approaches. Varibar is the only FDA-approved barium sulfate contrast product line for evaluation of swallowing using the MBSS. 11-15 Varibar products are multi- use and vary in consistency from thin to thick, with each consistency de- Diagnosis and Management of Swallowing Physiology: Standardized Contrast, the MBSImP™, & the IDDSI Framework