The Development of a Standardized Videofluoroscopic Swallow Study Barium Mixing Protocol: A Consensus-Based Approach

Videofluoroscopic swallow assessments are considered the gold standard for dysphagia evaluation. Despite widespread use in clinical and research settings, standardization of barium mixing protocols is lacking. This study compared current barium mixing protocols across four Canadian acute care centres and aimed to establish standard consensus-based protocols for select target textures (i.e., thin liquid, nectar thick liquid, honey thick liquid, puree, and solid) feasible for clinical and research implementation. A representative speech-language pathologist at each site responded to an online questionnaire regarding their current barium mixing protocols. Each liquid protocol was assessed for accuracy in meeting its target using the International Dysphagia Diet Standardisation Initiative Flow Test. Early consensus was reached to use pudding and a biscuit as targets for puree and solid textures, respectively. The mixing protocols which met these criteria moved through the iterative feedback process with participating sites, identifying the protocol considered most accurate and feasible. Survey data identified use of common products across institutions, but barium mixing protocols differed. Flow Test results eliminated liquid mixing protocols that failed to align with our criteria. Acceptable liquid, puree, and solid protocols were reviewed by sites for feasibility of mixing, perceived accuracy, and visibility on imaging. Through this process, a single consensus-based barium mixing protocol was established for each target texture. Reproducibility for each final protocol was established by two sites. The iterative review process, clinician feedback, and Flow Test results successfully established barium mixing protocols for several textures which have the potential for widespread implementation.