Integrating Respiratory Patterns into Your Clinical Swallow Exam

Why You Should Be Assessing Respiration During Swallow Evaluations

When it comes to evaluating swallowing function, respiration is often overlooked. Yet the coordination between respiration and swallowing is a critical factor in airway protection, especially for patients with dysphagia. So, how do you assess respiration during a swallow evaluation—and are you doing it at all?

Let’s break down the why, the how, and the tools that can support a more thorough and evidence-based assessment.

Why Respiration Matters in Swallowing

Respiration and swallowing share anatomical and neurological pathways, making their coordination essential for safe and efficient swallowing. In fact, many muscles and structures involved in swallowing also play roles in breathing. The act of swallowing requires a brief period of apnea, or cessation of breathing, which must be precisely timed within the respiratory cycle to prevent aspiration.

Most healthy individuals follow an exhale–swallow–exhale pattern. This pattern allows a partial exhale before the swallow and the completion of that exhale afterward, helping to clear any residual material from the airway.

Dr. Bonnie Martin-Harris and colleagues have done extensive work in this area. Research has shown that disruptions in the respiratory-swallow pattern—such as inhalation immediately following a swallow—can significantly increase the risk of aspiration, particularly when residue remains in the pharynx or larynx (Martin-Harris et al., 2005).

Observational and Instrumental Tools for Assessing Respiration

So how can you assess respiration in your clinical swallow evaluation?

1. Observation

Carefully watch your patient’s breathing patterns before, during, and after swallowing. Are they gasping? Are they inhaling immediately after the swallow? Do they appear short of breath or fatigued?

2. Cervical Auscultation

Cervical auscultation can be a helpful adjunct tool. With a stethoscope placed on the neck, you can often detect the apneic pause during swallowing and observe the inspiration/expiration pattern. While not a standalone diagnostic method, it can help identify atypical coordination (Stroud et al., 2020).

3. Modified Barium Swallow Study (MBSS)

MBSS can visually capture post-swallow inhalation, especially when pharyngeal residue is present. You may observe a patient beginning to inhale while residue remains in the pharynx—placing them at high risk for aspiration.

4. Passy-Muir Resources

The Passy-Muir Valve team has a helpful video on YouTube showing normal respiration and swallowing patterns. This visual can be useful for patient education or team training.

Implications for Swallowing Interventions

Many compensatory strategies we use in therapy—such as the super supraglottic swallow—alter the natural breathing-swallowing rhythm. These maneuvers typically require a deep breath, a breath-hold, and a volitional swallow. However, this pattern can be problematic:

Holding a full breath may interfere with the natural exhale-swallow-exhale pattern.
Cognitive load from complex instructions can result in mistimed breathing or incomplete closure.
Some patients may accidentally inhale instead of exhale immediately after the swallow, increasing aspiration risk.

What Can We Do Instead?

Use visual cues to guide breath control during swallowing maneuvers.
Simplify directions by coaching patients to “inhale, exhale a little, hold, swallow, exhale.”
Reinforce the exhale-swallow-exhale pattern with biofeedback or modeled breathing patterns.

The Neurophysiology of Breathing and Swallowing

The coordination between breathing and swallowing is governed by complex neural circuits in the dorsomedial and ventrolateral medulla—with support from cortical structures for volitional control. The timing of the apneic pause, the respiratory phase in which swallowing occurs, and the duration of respiratory inhibition are all critical for airway protection (Martin-Harris et al., 2005; Martin-Harris & McFarland, 2020).

Clinical Takeaway

Given the overlap in anatomy, neurology, and muscle function, failure to assess respiration during a swallow evaluation is a missed opportunity. Understanding your patient’s respiratory-swallow pattern can help you:

Identify aspiration risk.
Customize compensatory strategies.
Improve the accuracy of your clinical impressions.
Advocate for instrumental assessment when needed.

Respiration is a vital part of your dysphagia evaluation toolbox. Don’t leave it out.

Are you ready for a deeper dive with even more resources available? Join the Dysphagia Skills Accelerator today. You will get so many great tools with new tools being added all the time! Click here to join now!

Have you ever wanted a way to create a more standardized protocol for your Clinical Swallow Evaluation? Do you often forget or leave out parts of the CSE, you know, the parts that are important for your Plan of Care? You probably need the Clinical Dysphagia Assessment Toolkit if you answered yes. You can get your copy here.

Want to Learn More?

Here are a few excellent articles to start with:

Martin-Harris, B., Brodsky, M. B., Michel, Y., et al. (2005). Breathing and swallowing dynamics across the adult lifespan. Archives of Otolaryngology–Head & Neck Surgery, 131(9), 762–770.
Martin-Harris, B., & McFarland, D. H. (2020). Respiratory–swallow training: A collaborative intervention for patients with dysphagia. Perspectives of the ASHA Special Interest Groups, 5(6), 1506–1516.
Hiss, S. G., Strauss, M., & Treole, K. (2003). Effects of bolus volume on swallowing coordination in healthy adults. Journal of Speech, Language, and Hearing Research, 46(3), 576–584.
Stroud, K. P., Boese, R. E., & Humbert, I. A. (2020). Cervical auscultation in clinical practice: A systematic review. Dysphagia, 35, 190–203.

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