1. BioVIEW Suite P Automated Chicago Analysis

2. Automated Chicago Classification Analysis Advanced Analysis Tutorial

3. Objectives Define the different Chicago Classification analysis marks and what they measure Explain the how to activate a measurement and display Chicago analysis marks Demonstrate how to adjust the Chicago analysis marks Discuss the appropriate order of operation between Chicago and conventional analysis Describe the Chicago analysis data on a report

4. Suite P Highlights Chicago measurements are automatically marked in the study The Chicago analysis marks are seen using the analysis tool in the contour view The Chicago marks show when the waveform is off The conventional marks show when the waveform is overlain on top of the contour The Chicago marks are visible in the active measurement (don’t vanish) The Chicago values populate to the report if the Chicago table option is checked

5. Muscle Segments All of the Chicago analysis marks are made in the smooth muscle segment of the esophagus The striated muscle segment extends 1-2 cm below the UES The smooth muscle segment extends from below the proximal pressure trough (or below the striated muscle if there is no visible pressure trough) through the distal esophagus and includes the LES

6. Contractile Deceleration Point CDP CDP The CDP is found 1.5 - 2cm above the proximal margin of the LES

7. Isobaric Contours The black contour line should be set at 30 mmHg and the blue or gray contour line should be set to 20 mmHg The CFV and the DL (the two marks that use the CDP) use the 30 mmHg isocontour The DCI and PB use the 20 mmHg isocontour

8. Temperature Compensation Required for Chicago Analysis - The flashing line can cross blue, green or yellow - The line should not cross red or orange where the probe was touched - The area where the curser was clicked turns all light blue if the compensation was done correctly - If it isn’t, delete and re-do -Click the curser just after extubation while the probe is still warm -Click on Edit -Scroll to and click on Create Compensation -To check if a compensation has been done already on this study, click Edit -If Create and Delete are both darkened, it has been done and need not be repeated

9. When the waveforms are overlain, the analysis will be conventional When the waveforms are off, The analysis will be Chicago Waveform button depressed (on) Waveform button raised (off)

10. Display of the Chicago Analysis Marks IRP – Integrated Relaxation Pressure DCI – Distal Contractile Integral DL – Distal Latency PB – Peristaltic Break CFV – Contractile Front Velocity

11. IRP – Integrated Relaxation Pressure Integrated Relaxation Pressure (IRP) is a measure of the extent of relaxation of the lower esophageal sphincter The IRP, measured in mmHg, is a box starting at the onset of 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

12. DCI – Distal Contractile Integral 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

13. DL – Distal Latency 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.

14. PB – Peristaltic Break 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 in the contraction.

15. CFV – Contractile Front Velocity Contractile Front Velocity (CFV) is a measure of contraction velocity in the peristaltic phase of the smooth muscle contraction sequence 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.

16. Symbols for Adjusting Chicago Analysis Marks Adjustment of the Chicago analysis marks is quite intuitive. The curser changes to different symbols to indicate that a certain mark can be adjusted with a left click and drag. A quad white arrow positioned in the lower right corner of the circle will adjust either end of the CFV tangent A white arrow will adjust margins of either an IRP or DCI box A plus symbol will adjust either end of a DL or PB line

17. To add a mark, right click inside the swallow measurement and select To delete a mark, right click on a line or margin of a box and select delete It doesn’t matter what the orientation is of the various marks. The reported values stay the same no matter which side of a line or box is up, down, left or right Analysis Marks – Orientation, Add/Delete and Linked Measurements that share same data points will move together when a mark is adjusted When the lower mark of the CFV is moved, the right end of the DL moves with it because they both share the CDP When the upper edge of the IRP box is moved, the lower edge of the DCI box moves with it because they both share the proximal edge of the LES (The lower edge of the DCI can be moved separately without bring the upper edge of the IRP along)

18. Analysis, Editing and Re-analysis When the analysis tool is activated for the first time by clicking on the analysis tool icon – the small black microscope - the computer analyzes the study both conventionally (waveform) and in the Chicago format (contour) A reviewer can move (edit) the analysis marks placed by the computer You may choose to re-analyze all of the measurements in a study or just a selected measurement. Re-analyzation will revert the analysis marks back to the where the computer originally placed them. But, if you are not aware what moves may lead to re-anlyzation, you may inadvertently make a change. If the reviewer wants the corrected data on the report, the measurement will have to be re-edited

19. Re-analyze All Measurements There are a few ways to re-analyze (return to computer analysis) All of the Measurements and a few ways to re-analyze only a Selected Measurement Perform or repeat a temperature compensation (see earlier slide) OR Click on Analyze and Analyze All Measurements To Re-analyze All Measurements:

20. Analysis and re-analysis will not move or change the shape of any of the swallow measurements, change the probe depth or affect the profile events (PIP, Proximal and Distal) Re-analyze a Selected Measurement To re-analyze a selected (active) measurement Click on Analyze / Analyze Selected Measurement OR Double left click inside the measurement -When the Change Measurement box opens, click the OK button at the bottom -Clicking the Cancel button will not re-analyze the selected measurement OR Re-size the measurement by left clicking and dragging one of the side margins IMPORTANT NOTE: Re-analyzing a measurement in the conventional view will re-analyze the same measurement in contour and visa versa Left click inside of a measurement box to activate this measurement. Only one measurement at a time can be the active box.

21. How to Avoid Inadvertently Re-analyzing a Measurement Perform a temperature compensation only once when a study is opened for the first time Review all measurements before editing, by tabbing through them: Delete unacceptable multiple swallows If needed, re-size any swallow measurements to completely envelope smooth muscle contraction pressures and make sure all channels are included in the Chicago measurement boxes If reporting conventional values; complete all waveform edits before editing the Chicago analysis marks Often, in waveform editing, the GBL is adjusted and Analyze All Measurements is clicked so the LESP and LES residuals will use the new GBL. If the Chicago marks were edited, and then the GBL moved and Analyze All Measurements is selected, the Chicago marks will revert to their original positions. If an individual Chicago measurement is re-analyzed after the waveform edits have already been done, you will need to flip back to waveform and re-adjust the conventional marks for this measurement again. The following steps will help you to avoid unintended re-analyzation of a measurement:

22. This Concludes the Advanced Analysis Tutorial Automated Chicago Classification Analysis The following documents are attached to this tutorial available for download Chicago Classification Quick Start Guide Chicago Marks: Re-analysis