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Respiratory Muscle Strength Training

Inspiratory Muscle Strength Training

 Inspiratory strength training works on the muscles of inspiration the diaphragm, the intercostals. Inspiration involves contractions of the diaphragm and external intercostals, which increase intrathoracic volume and decreased volume in pressure.

 Respiration is a recoil from inspiration. Exhalation involves relaxation of the inhalation muscles, recruitment of abdominal and internal intercostals to force air out of the lungs.

Under Pressure

Pressure Threshold Devices are recommended for RMST. There are devices for Inspiratory Muscle Strength Training (IMST) and for Expiratory Muscle Strength Training (EMST).

For Dysphagia

 In dysphagia, EMST was found not only to increase greater force with the cough, enabling the patient to produce a more productive cough forcing material from the airway, but also was found to increase hyolaryngeal excursion and velar closure.

 EMST is not recommended for those on supplemental oxygen, those with COPD or people with untreated GERD.

 The EMST 150 device is a pressure threshold device with a high number of settings, AND it is the device that was used during the study. The EMST 150 is is found on the here and is relatively inexpensive at $54.95 each.  The patient used the device 5 times, 5 times a day for 5 weeks, using the “Rule of 5.”

When focusing on EMST and IMST in your therapy, you want to find a pressure threshold device to achieve maximum results similar those found in the research as referenced below.  Resistive devices may offer various levels of resistance, or a number of holes/notches which to increase the device.  Resistance can be increased or decreased depending on patient needs and function.  The Pressure Threshold Devices offer more.  Resistive devices are:  Expand-a-Lung, The Breather, PFlex and BreathBuilder.

 RMST is also indicated for voice disorders, bilateral vocal fold paralysis, professional voice users, sedentary elderly, Parkinson’s Disease (PD), Multiple Sclerosis (MS), Huntington’s, Progressive Supranuclear Palsy (PSP), stroke, healthy elderly.  RMST can also be used for ventilator weaning.

Read More 

For more information on RMST please read the following:

 EMST and Parkinson’s Disease


EMST with MS

A large number of articles regarding RMST

EMST Swallowing and PD

 Sapienza, C.M., Davenport, P.W., & Martin, A.D. (2002).  Expiratory muscle training increases pressure support high school band students.  Journal of Voice, 16, 495-501.

 Burkhead, L.M., Sapienza, C.M. & Rosenbek, J.C. (2007).  Strength-Training Exercise in Dysphagia Rehabilitation:  Principles, Procedures and Directions for Future Research.  Dysphagia 22, 251-265.

 Sapienza, C.M. (2008).  Respiratory Muscle Strength Training Applications.  Current Opinion in Otolaryngology & Head and Neck Surgery, 16, 216-220.

 Pitts, T. et al.  (2009).  Impact of Expiratory Muscle Strength Training on Voluntary Cough and Swallow Function in Parkinson’s Disease.  Chest, 135(5), 1301-1308.

 Wheeler-Hegland K.M., Rosenbek J.C. & Sapienza, C.M. (2008).  Submental sEMG and Hyoid Movement During Mendelsohn Maneuver, Effortful Swallow, and Expiratory Muscle Strength Training.  JSLHR 51, 1072-1087.

You can also read more on the EMST 150 Website.

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Go With the (Peak) Flow


A Clinical Swallow Evaluation is a series of screens that we use to determine if the patient requires more testing or not.

Let’s face it, whether we like it or not, insurance likes objective data, including numbers indicating a deficit or no deficit.   Peak Flow is a tool that gives us objective numbers to input into our reports.

What is Peak Flow?

A Peak Flow meter measures how fast air is expelled from the lungs in one fast blast.  A Peak Flow meter can be very beneficial to those with asthma.

Peak Flow also gives us information on the cough reflex and function of the cough, in turn, allowing us to determine patients that are at risk for penetration and/or aspiration.

Why do we care about coughing?

Coughing is a mechanism of airway clearance that adds to normal
ciliary function comprised of three events

  • Inspiratory effort
  • Followed by rapid vocal fold adduction
  • Contraction of the expiratory muscles

Respiratory Muscle Strength Training (RMST)

You can also use Peak Flow to determine baseline for RMST and to measure outcomes throughout your therapy using RMST.

So what has research told us about measuring Peak Flow?

We measure using PEF or Peak Expiratory Flow or PEFR Peak Expiratory Flow Rate.

  • Smith-Hammond, et al 2009-Peak flow identified 82% of aspirators
    (stroke patients) at PEF <2.9 L
  • Pitts, et al  2010-Peak flow identified 86% of aspirators (Parkinson’s) at
    PEF <5.2 L
  • Suarez, et al 2002 identified 74% aspirators (ALS) at
    <4.0 L
  • Plowman, et al 2016 identified voluntary cough airflow in patients with ALS at risk for penetration/aspiration

Peak Flow meters can be purchased to use.

PF 1        PF 2

A less expensive Peak Flow model will have a plastic piece on the side that moves as the person exhales or coughs into the device.   You can determine the PEF or PEFR by having the person exhale or cough into the device 3 times and figuring the average rate.

PF 3

You can also purchase a digital device which will give you a more accurate reading, but will cost you a bit more.

These devices can be purchased on Amazon or a medical supply store.   You can often purchase disposable mouth pieces so that you can use the device with multiple patients after cleaning.


Gregory, S. A. (2007). Evaluation and management of respiratory muscle dysfunction in ALS. NeuroRehabilitation22(6), 435-443.

Hammond, C. A. S., Goldstein, L. B., Horner, R. D., Ying, J., Gray, L., Gonzalez-Rothi, L., & Bolser, D. C. (2009). Predicting aspiration in patients with ischemic stroke: comparison of clinical signs and aerodynamic measures of voluntary cough. Chest135(3), 769-777.

Pitts, T., Troche, M., Mann, G., Rosenbek, J., Okun, M. S., & Sapienza, C. (2010). Using voluntary cough to detect penetration and aspiration during oropharyngeal swallowing in patients with Parkinson disease. Chest138(6), 1426-1431.

Plowman, E. K., Watts, S. A., Robison, R., Tabor, L., Dion, C., Gaziano, J., … & Gooch, C. (2016). Voluntary cough airflow differentiates safe versus unsafe swallowing in amyotrophic lateral sclerosis. Dysphagia31(3), 383-390.

Suárez, A. A., Pessolano, F. A., Monteiro, S. G., Ferreyra, G., Capria, M. E., Mesa, L., … & De Vito, E. L. (2002). Peak flow and peak cough flow in the evaluation of expiratory muscle weakness and bulbar impairment in patients with neuromuscular disease. American journal of physical medicine & rehabilitation81(7), 506-511.