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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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Respiration and Swallowing

How do you assess respiration when completing a swallow evaluation?

Do you assess respiration during a swallow evaluation?

What methods can be utilized to assess respiration during swallowing?

There are several really good articles available.  Dr. Bonnie Martin-Harris has been a leader in researching respiration and swallowing.

Below are links to a few abstracts of articles available regarding respiration and swallowing:

Coordination between respiration and swallowing: respiratory phase relationships and temporal integration.


Passy-Muir has uploaded a video of normal respiration and swallowing on YouTube.

The Lungs

The lungs are the organs that transfer oxygen from the atmosphere to the bloodstream and carbon dioxide from the bloodstream to the atmosphere.  The lungs are spongy and moist, making them susceptible to bacteria.  The right lung contains 3 lobes while the left lung only has 2 lobes.  Aspiration can occur in either lung, depending on many factors including positioning of the patient. 

For more information on the lung, follow this link.  Lung


Cervical Auscultation can actually be very useful in determining respiration in conjunction with the swallow.  You can hear that period of apnea when that patient ceases breathing to swallow.  You can also listen to the sounds of expiration and inspiration to determine the patient’s pattern of breathing in regards to swallowing.

Most people tend to use an exhale-inhale-exhale-swallow-exhale pattern of breathing.    The theory is that you exhale partially, swallow then complete the exhale as a defense mechanism to clear the airway of any residue that may remain. 

You may want to look at Cervical Auscultation:  A Systematic Review.

It is also important to watch your patient.  If they inhale immediately following a swallow, that may be a large risk factor, particularly if that patient has laryngeal or pharyngeal residue following the swallow.  This may also be observed via MBSS.  There are times you can watch the patient actually INHALE the pharyngeal residue before they can attempt to clear.

What about some of the compensations ortechniques that we ask our patients to use??

Think about those super supraglottic and supraglottic swallows that we ask our patients to use or the breath hold maneuvers

We typically say to take a deep breath and hold it.  Try to do that.  Then swallow.  Seriously, try it.

When you take a deep breath and hold it, 1.  we are offsetting that exhale-swallow-exhale routine and 2. it’s not easy to swallow when your lungs are full of air. 

Another issue may be that the patient becomes confused with the numerous directions they must follow to complete this technique and inhale and/or exhale at the wrong time aspiration. 

What can we do to alleviate these issues??

For one thing, we can add visual cues for the completion of the super and supraglottic swallows.  This alleviates the memory issue to some degree.

We can also have the patient inhale, exhale slightly and then hold their breath, swallow and exhale.  This alleviates some of the pressure within the lungs and resets that exhale-swallow-exhale pattern that is more normal.

Some key points from Dr. Martin Harris

  • Breathing and swallowing processes are closely interrelated in their central control and are highly coordinated.
  • Many muscles and structures have dual roles in respiration and swallowing.
  • Neural control centers responsible for coordination of breathing and swallowing are contained in the dorsomedial and ventrolateral medullary regions of the brainstem.
  • Cortical structures also play an important role in facilitating and modulating the coordination of breathing and swallowing.
  • Relationship of the phase of respiration (i.e., Inspiratory, Expiratory, Transition) and duration of the apneic phase associated with swallowing have been extensively investigated.
  • Studies of swallowing dynamics and pulmonary function are needed that will investigate the clinical relevance of integrated breathing and swallowing function on the health and nutritional outcomes of dysphagic patients and patients with pulmonary disorders.

Coordination of Mastication, Swallowing and Breathing

Given the close relationship of the structures, cortical structures and muscles, to not assess respiration should not happen.  It is vital to understand the respiration/swallowing relationship.  
Assessing respiration is another tool in your dysphagia evaluation toolbox.