Ambulatory pH Studies : Bravo vs' Catheter probe

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Ambulatory pH Studies Bravo vs. Catheter probe

• Janet R. King BSN,RN,CGRN

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Motility Team

• A small group of GI Physicians and Nurses with a
  special interest in motility and pH procedures
• Allows for frequent participation in
  motility practice
• Proficiency is developed and maintained

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pH Studies

• Measures the reflux of acid into the esophagus
  during a 24hr or 48 hour period
• Provides information regarding
• Duration of reflux
• Frequency
• Timing
• Correlation

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24 hr Ambulatory pH Study
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pH Studies

• ADVANTAGES
• Detects reflux events under normal physiologic
  conditions and activity
• Longer monitoring period
• Symptoms can be correlated with episodes of
  Reflux
• Allows determination of efficacy of therapy

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pH Studies

• Indications
• Evaluate acid exposure prior to anti reflux
  surgery
• Evaluate following anti reflux surgery a patient
  still having ongoing reflux
• Evaluate patients on proton pump inhibitors still
  having reflux symptoms
• Evaluate GERD patients with laryngitis or chronic
  cough while on PPI for at least 4 weeks
• Evaluate patients for gastro esophageal
  reflux-induced asthma

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pH Studies

• Insight to information Gained
• Symptom correlation
• Extra esophageal presentations
• Evaluation of Patients experiencing no relief
  after medical therapy
• Reflux patterns
• Confirmation of GERD before Anti reflux surgery
• Assessment of proton pump inhibitor therapy

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Two methods to obtain a pH Study

• 1. Catheter 24 hr pH Monitoring System
• 2. Catheter Free 48hr pH Monitoring System
  (Bravo)

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Catheter pH Studies

• Single Channel pH study -
• One sensor placed 5cm above the Lower esophageal
  sphincter (LES)
• Double Channel pH study
• 2 Channel Gastric
• 2 Channel ENT
• 2 Channel Pulmonary

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2 Channel Pulmonary pH Study
UES
LES
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2 Channel Study Positive Cough
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2 Channel Study Chest Pain
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2 Channel Study Gastroesophageal Reflux
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2 Channel StudyPoor Symptom Correlation
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Requires Manometry Pre-Procedure
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Nursing Careprovided for pH study

• NPO status
• Medications last taken
• Explanation of the procedure
• Positioning
• Sensation experienced
• Length of procedure
• Evaluate anxiety level of patient

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Nursing Care provided for pH study

• Encourage cooperation by the patient
• Control issue
• Emotional support
• Step by step instruction
• Physical comfort
• Positive reinforcement

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Catheter pH StudiesProcedure steps

• Patient in sitting position
• Lidocaine spray to nostril
• Lubricated catheter is placed to back of throat
• Patient then lowers chin and sips water through
  straw
• Catheter is inserted with patient swallowing
• Check pH reading on digitrapper box
• Position catheter according to type of pH
  monitoring ordered

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pH catheter placement
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Catheter 24 hr pH monitoring system
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Limitations of 24 hr pH Catheter monitoring
system

• Patient Intolerance to the catheter
• Nasal pharyngeal irritation or pain
• Epitaxis
• Runny Nose
• Dysphagia
• Change in patient activity level
• Decrease in diet intake and physical activity
• Technical Limitations of the ph probe
• catheter drifting, poor positioning,
• Short recording period (24 hrs)
• Requires Manometry procedure first

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Bravo 48 hr Catheter free pH monitoring System
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Bravo pH Capsule with Delivery System

• For trans-nasal or trans-oral placement
• Single-Use item
• One-handed operation
• 100 cm long with working length of 80 cm
• Distance marks every 5 cm up to 60 cm

Handle
Catheter
pH Capsule
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BRAVO 48 hr pH Study

• pH Capsule
• size of a gel cap
• Dimensions 6 x 6.3 x 26 mm
• Measures esophageal pH
• Radio-Telemetry sends the data to the Receiver
  box
• Contains suction chamber, locking pin,
  transmitter and pH sensorref

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Methods of placing Bravo

• Transnasal (TN) placement
• Transoral (TO) placement
• With Endoscopy
• Without Endoscopy

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Transoral placement with Endoscopy

• Done in Endoscopy Suite
• EGD preparaton
• Patient will be receiving procedural sedation
• Medications last taken
• Explanation of the EGD procedure including Bravo
  placement

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Transoral pH Bravo Capsule placement
Endoscopically
Squamous Epithelium
6 CM
Columnar Epithelium
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Picture 7
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Bravo 48 hr pH Study
pH Capsule
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Transoral placementWithout Endoscopy

• Done in the Motility Room
• Manometry procedure required 1st
• Patient to be NPO for 6 hrs
• Patient will not receive Procedural Sedation
• Topical anesthesia is used
• Medications last taken
• Explanation of procedure process

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Transoral pH Bravo Capsule placement Without
Endoscopy
American Journal of Gastroenterology 2007
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Nursing Careprovided for pH study

• NPO status
• Medications last taken
• Explanation of the procedure
• Positioning
• Sensation experienced
• Length of procedure
• Evaluate anxiety level of patient

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Nursing Care provided for pH study

• Encourage cooperation by the patient
• Control issue
• Emotional support
• Step by step instruction
• Physical comfort
• Positive reinforcement

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Transoral placement without Endoscopy Procedure
Steps

• Patient in sitting position
• Give patient emesis basin
• Benzocaine spray to back of throat
• Tuck Chin to Neck
• Insert applicator with capsule facing tongue
• When at appropriate level Ask patient to
  speak
• Suction is applied for 45 seconds then release
  the capsule

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Capsule Attachment and Release
Step 1 Position Bravo Capsule
Step 2 Apply Suction
Step 3 Advance Pin
Step 5 Begin pH Recording
Step 4 Release Capsule
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Bravo 48 hr Ph monitor system
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Bravo Study

• Advantages
• No nasal pharyngeal irritation
• Patient freedom to maintain normal daily
  activities
• Eliminates catheter movement
• Longer recording periods (48 hrs)

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Bravo Study

• Limitations
• Requires EGD or manometry to determine placement
  of capsule
• Early capsule detachment
• Some patients experience vague chest discomfort
  or foreign body sensation

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In Summary

• Ambulatory pH studies is the most effective
  test to document
• Abnormal esophageal acid exposure
• Duration and frequency of reflux events
• Correlation of symptoms and reflux
• Which Method?
• Catheter vs. Catheter free (Bravo)

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Bibliography

• Lacy, B., OShana, T., Hynes, M. (2007). Safety
  and Tolerability of Transoral Bravo Capsule
  Placement. American Journal of Gastroenterology.
  102, 24-32.
• Lazarescu, A., Sifrim, D. (2008) . Ambulatory
  Monitoring of GERD Current Technology.
  Gastrointestinal Clinics North America. 37,
  793-805.
• Pandolfino, J., Richter, J., Ours, T. (2003).
  Ambulatory Esophageal pH Monitoring Using a
  Wireless System. American Journal of
  Gastroenterology. 98, 743-749.
• Prakash, C., Clouse, R., (2006). Wireless pH
  Monitoring in Patients with Non-Cardiac Chest
  Pain. American Journal of Gastroenterology. 101,
  446-452.
• Schuster, M., Crowell, M., Kock,K. (2002).Atlas
  of Gastrointestinal Motility in Health and
  Disease. Canada BC Decker Inc.