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Case Reports |
VC Warren, PT, is Physical Therapist II, Rancho Los Amigos National Rehabilitation Center, 7601 E Imperial Hwy, Downey, CA 90242 (vwarren{at}dhs.co.la.ca.us)
Submitted February 21, 2001;
Accepted December 22, 2001
 | Abstract |
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Key Words: Emergency breathing techniques • Glossopharyngeal breathing • Neck accessory muscle breathing
| Introduction |
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 TopAbstract Introduction Case DescriptionInterventionGlossopharyngeal BreathingOutcomesDiscussionReferences |
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Glossopharyngeal breathing involves a series of gulps using the lips, tongue, pharynx, and larynx to pull air into the lungs when the normal inspiratory muscles are not functioning5 (Fig. 1). Glossopharyngeal breathing consists of cycles of 6 to10 gulps of air followed by exhalation. Exhalation occurs when the glottis opens and the inflated lungs deflate passively due to the elastic recoil of the lungs. In addition, GPB has been recommended to allow an individual to perform a functional cough to clear tracheal secretions, increase the volume of the speaking voice, and maintain chest wall mobility.9,10
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Johnson et al15 presented a case study of a patient with Duchenne muscular dystrophy who was dependent on a ventilator and able to quadruple his vital capacity with GPB. Using GPB, he could count to 25 with a vital capacity of 1,200 cc. He used GPB for up to 2 hours and was able to vocalize. As his disease progressed, however, his vital capacity was reduced to zero, and he was unable to articulate a count of 1.
People who are dependent on a ventilator as the result of a spinal cord injury, however, are different from people with poliomyelitis and Duchenne muscular dystrophy because they usually have both sensory and motor loss of the muscles of respiration. People with poliomyelitis and Duchenne muscular have motor loss only.
Patients with spinal cord injuries who were not on ventilators have been reported to learn GPB. Metcalf13 published the first study, which involved 23 adults with C4 to T1 complete tetraplegia. Using GPB, the subjects' vital capacity increased to 81% of normal, they were able to perform an effective cough independently, and they maintained pulmonary compliance and thoracic mobility.
Montero et al14 described 14 people with C5 to C7 complete tetraplegia, aged 15 to 37 years. Using GPB, the subjects added 700 to 1,000 cc of air to their vital capacity, a gain of 28% of normal. Overall, vital capacity increased from 35% to 65% of normal. While performing GPB, they were able to clear secretions from their throats and increase the loudness of their voices.
One report18 described an individual who was dependent on a ventilator secondary to a spinal cord injury and attempted to learn GPB, but did not succeed. She instead learned to use her neck accessory muscles to breathe when she was off the ventilator. Neck accessory muscle breathing is the only reported emergency breathing technique taught to people who were dependent on a ventilator secondary to a spinal cord injury.7,8,18 These reports7,8,18 involved children and one adult.
Gilgoff et al7 instructed 7 children with tetraplegia, aged 2 to 16 years, who were dependent on a ventilator to successfully breathe off their ventilators with neck musculature for 20 minutes to 2 hours. Morrison8 used biofeedback to teach a 30-year-old adult with C1 complete tetraplegia to use his neck accessory muscles to breathe off a ventilator for 35 minutes. When the biofeedback was removed, time off the ventilator decreased to 7.5 minutes.
Donovan and Taylor18 described an 11-year-old girl with C2 complete tetraplegia who attempted to learn GPB over a 3-month period. The GPB program was discontinued because she developed use of her accessory respiratory muscle, the sternocleidomastoid, which allowed her to breathe off the ventilator for up to 1 hour. She had a tidal volume of 50 to 100 cc and a respiratory rate of 22 breaths per minute. She was also able to speak 3 to 4 words per breath while off the ventilator. Two years later, she was able to breathe off the ventilator for up to 2
hours as she continued to strengthen her accessory muscles by breathing off the ventilator 2 to 3 times per day.
Many patients today who are dependent on a ventilator as the result of spinal cord injuries might benefit from learning GPB and NAMB. In my opinion, both techniques are important for patients who are dependent on the ventilator to learn because each has advantages and disadvantages. Compared with NAMB, advantages of GPB that I have observed include allowing the patient to develop a larger vital capacity, which can be used to breathe off the ventilator for a longer period of time or to produce a more productive cough to clear tracheal secretions. The disadvantages of GPB include being more difficult to learn and the need to close off the individual's tracheostomy by use of a Passy-Muir valve or cover the opening after accidental disconnection. If the person becomes disconnected above the Passy-Muir valve and the tracheostomy is open, GPB cannot be used because the accumulated air escapes out of the tracheostomy where the ventilator tubing was attached prior to accidental disconnection. If this occurs, the individual must rely on NAMB. In contrast to GPB, NAMB is easy to learn and can be used as an emergency breathing alternative without concern for the site of disconnection. Small volumes of air can be generated to breathe off the ventilator for a more limited time period, however, than with GPB. The heavier the individual, the greater the vital capacity and tidal volume needed to breathe off the ventilator. In my experience, neck accessory muscles cannot generate enough volume of air to allow heavier individuals to breathe off the ventilator for longer than a few weeks. In addition, with NAMB each inhalation is individually transmitted into the lungs, whereas with GPB several gulps of air are accumulated in the mouth before the volume of air is transmitted to the lungs.
Glossopharyngeal breathing has been taught to people using several similar methods. Dail et al5 learned GPB by studying fluoroscopy, cineflurography, spirography, pneumotachography, and airway pressure measurements and by examining patients and staff who had learned the technique. They reported that, of 100 patients with poliomyelitis, 55 patients were taught GPB by hospital staff, 25 learned with minimal assistance of others, 15 learned from other patients, and 5 learned by themselves without being aware of what they were doing. Patients have been taught GPB by first receiving an explanation of GPB, then watching a movie or videotape of someone performing GPB.9,15 Patients were trained for 30- to 60-minute sessions 3 to 5 days per week.9,15
The purpose of this case report is to describe a 5-week program to teach of an adult male patient with C2 complete tetraplegia to use alternative breathing techniques. The physical therapist and the physical therapist assistant taught the patient both GPB and NAMB.
| Case Description |
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TopAbstractIntroductionCase DescriptionInterventionGlossopharyngeal BreathingOutcomesDiscussionReferences |
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months due to medical complications at an acute care hospital prior to being admitted to a rehabilitation center as an inpatient.
Examination
The initial examination indicated that the patient was fully dependent on the ventilator; had no diaphragm movement, as indicated by manual palpation; and had a nonfunctional cough.19 Cough function can be classified as "functional" when a person is able to clear all tracheal secretions independently, "weak functional" when a person is able to clear the throat and small amount of secretions with minimal cough force, or "nonfunctional" when a person is unable to generate any cough force.19
The examination also indicated that the patient had 3 mm of chest expansion at the xiphoid process17,20 and a vital capacity17,21 of 75 cc when off the ventilator. The vital capacity measurement was taken following the testing procedure of the American Association for Respiratory Care Clinical Practice Guidelines21 with a hand-held Mark 14 Wright respirometer.*,22,23 Each time I measured the patient's vital capacity, I used the same method and recorded the highest of the 3 trials. I did not determine the reliability of the measurements. His initial ventilator settings were the following: tidal volume: 800 cc, mode: assist control, rate: 14 breaths per minute, and fraction of inspired oxygen (FIO2): 30%. His blood gas values were: pH: 7.40, arterial partial pressure of oxygen (PaO2): 156 mm Hg, partial pressure of carbon dioxide (PCO2): 35 mm Hg, bicarbonate (HCO3): 21, oxygen saturation: 99%, and Sigh: 1,200 cc. The patient was placed on room air 22 days after the initial admission. His FIO2 was decreased to 25% in the morning and to room air (21%) in the later afternoon. The ventilator settings remained unchanged.
To assess whether the muscles of respiration were innervated, manual muscle testing was performed.20 The patient had 4/5 strength of his upper trapezius, sternocleidomastoid, neck flexor, and neck extensor muscles. At the time he began the GPB and NAMB programs, he was able to sit up daily in a chin-controlled, battery-powered wheelchair with supervision24 within the hospital ward and contact/steady assistance when operating the wheelchair outside on unlevel terrain.
The power wheelchair involved use of the neck muscles, including the muscles of respiration. For example, the sternocleidomastoid muscle is used to assist with turning and backing up the wheelchair. This activity may have contributed to strengthening his neck accessory muscles. In addition to physical therapy, he practiced using a mouth stick device25 to assist with turning pages, operating a telephone, and using a computer with his occupational therapist. This patient was able to learn new skills and information quickly, and he appeared to want to learn as much as he could.
| Intervention |
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TopAbstractIntroductionCase DescriptionInterventionGlossopharyngeal BreathingOutcomesDiscussionReferences |
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The patient began to learn GPB once he was able to tolerate breathing with a nonfenestrated cuffless tracheostomy and Passy-Muir valve.
First, the pulmonary physician changed his tracheostomy from a nonfenestrated cuffed tube to a cuffless tube. The cuff was deflated 12 days after admission and was changed to a cuffless tracheostomy 4 days later. The ventilator setting remained the same as it was initially, except the Sigh increased from 1,100 cc at initial cuff deflation to 1,200 cc with cuffless tracheostomy (Fig. 3).
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The Passy-Muir valve is a one-way valve that is placed between the Bodai tracheostomy adapter
and mechanical flex-tubing (Flex tube
) when used in conjunction with the ventilator. The Bodai tracheostomy adapter is used because it provides easy access for suctioning and is comfortable for the patient. When the ventilator tubing is moved there is less pressure on the stoma because the Bodai tracheostomy adapter rotates on the tracheostomy (Fig. 4).
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The Passy-Muir valve allows the inhaled air from the ventilator to fill the patient's lungs, but does not allow the exhaled air to flow out through the tubing for expiration. Instead, the expired air is directed out through the nose and mouth. During inhalation, the Passy-Muir valve prevents air from escaping out through the tracheostomy tubing and directs it into the lungs. The Passy-Muir valve also directs air past the vocal cords for speaking during exhalation. The manufacturer states that inflation of the patient's cuffed tracheostomy when the Passy-Muir valve is in place would cause suffocation because the air the patient receives from the ventilator would be trapped between the lungs and the Passy-Muir valve,26 which is why a cuffless tracheostomy is used with the Passy-Muir valve.
| Glossopharyngeal Breathing |
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TopAbstractIntroductionCase DescriptionInterventionGlossopharyngeal BreathingOutcomesDiscussionReferences |
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) to the ventilator tubing at the level where the tubing attaches to the trachea adapter. The patient would then accept air from the ventilator into his mouth instead of into his trachea. The ventilator settings were not changed from those set when the air entered through his tracheostomy. This manner of breathing with the ventilator mouthpiece will be referred to as mouth positive air. To prevent the air coming into his mouth from escaping through the trachea where it attaches to the flex-tubing, a Passy-Muir valve was put in place between the Bodai tracheostomy adapter and the mechanical flex-tubing. The patient wore the Passy-Muir valve whenever GPB training occurred. While the patient used the air to breathe from his ventilator into his mouth, he learned 2 primary skills necessary for learning GPB. First, he learned how to close off his nasopharynx as he inhaled the air coming into his mouth from the ventilator. I placed a mirror under the patient's nose. If the mirror did not fog during inhalation, then the patient was achieving adequate closure of his nasopharynx. The second skill was to ensure that the patient's chest was rising during inhalation while he received air into his mouth from the ventilator. The patient's chest rising during inhalation indicated that the air was going into his lungs. By the end of the first week, the patient was able to breathe comfortably for 5 minutes with the ventilator delivering air into his mouth.
The second week involved teaching the patient 3 additional exercises that are similar to performing GPB. These exercises were taught while the patient used mouth positive air.
The first exercise involved having the patient take a breath of mouth positive air, close his glottis to keep the air in his lungs, open his mouth, pause, then exhale the air by making an "ahhhhhh" sound. This exercise was intended to help the patient to learn how to open and close his glottis.
The second exercise taught him how to open and close his vocal cords quickly to close his glottis for alveolar gas exchange. When a gulp of air is taken into the pharynx during GPB, the vocal cords need to be opened and closed quickly to trap air below the glottis and the lungs. He performed this second exercise by taking a breath of mouth positive air, closing his glottis to keep the air in his lungs, opening his mouth, pausing, then exhaling by quickly starting and stopping the flow of air while making a sharp "ah, ah, ah" sound until all of the breath of air was exhaled. He was instructed to make this sound quickly and staccato-like.
The third exercise was intended to help the patient to learn to depress and elevate his larynx while holding air in his closed glottis. This involved taking a breath of mouth positive air, closing the glottis, opening his mouth, and then depressing and elevating the posterior portion of his tongue several times while the tip of the tongue maintained contact behind the posterior lower dentition. Then he exhaled the air held below his glottis.
By mimicking the physical therapist and occasionally watching himself in the mirror, the patient was able to perform a GPB stroke (steps 1–4 in Tab. 2). He was instructed to make an "up" sound with each gulp of air (GPB stroke) while his lips moved in the shape of "oop." Oxygen saturation was monitored during these exercises and never dropped below 97% of normal.
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The patient had mastered the GPB stroke by the fourth week. He had a vital capacity of 2,000 cc after 22 minutes off the ventilator with oxygen saturation at 96% and above. At this point, I compared the patient's chest expansion with the ventilator with expansion while using GPB off the ventilator. He was able to expand his chest, measured at the xiphoid process, 9 mm with GPB off the ventilator compared with 3 mm with the ventilator alone. In addition, he was able to perform a weak functional cough both on and off the ventilator using GPB. A weak functional cough would allow him to clear some tracheal secretions independently.19 He accomplished this cough by first holding a breath from the ventilator in his lungs, then performing GPB, and coughing just prior to the next ventilator breath. His vital capacity with coughing was 3,000 cc.
After 5 weeks of GPB training 3 to 4 times per week for 20- to 30-minute sessions with the physical therapist or physical therapist assistant, the patient was able to use GPB to breathe off the ventilator for 30 minutes (Fig. 6).
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After 4 weeks of training, the patient was able to use his neck accessory muscles to breathe off the ventilator for 2 minutes before his oxygen saturation level dropped below 90% of normal. Further training was discontinued because the patient was frustrated with his lack of progress.
| Outcomes |
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TopAbstractIntroductionCase DescriptionInterventionGlossopharyngeal BreathingOutcomesDiscussionReferences |
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The patient was only able to use NAMB for 2 minutes before his oxygen saturation level dropped below 90% of normal. After 4 weeks, training to breathe with neck accessory muscles was discontinued because the patient became frustrated with his lack of progress.
The patient was discharged from the rehabilitation center to a residential home that provided 24-hour nursing care. While at this home, he was encouraged by the nursing staff to continue to practice NAMB off the ventilator. The patient stated that he was able to breathe off the ventilator with his neck accessory muscles for 4 minutes at a time after living at the residential home for 2 years. He rated difficulty in learning to use his neck accessory muscles to breathe off the ventilator as 9 out of 10, where 10 is "very difficult."
I interviewed the patient by telephone 4 years after his inpatient rehabilitation program. He was living in his own home with 24-hour nursing care while attending college to obtain a degree in computer science. When asked to recall his experience learning GPB, he commented that he knew he was getting air into his lungs with GPB because he could see his chest rising and his ribs expand. He explain that he used counting as a method to pace himself to ensure he would not breathe too rapidly, become anxious, and then become tired when using GPB to breathe off the ventilator. He would exhale once he had a feeling he could not accommodate further breaths. He reported that the easiest portion of performing GPB is pushing the air into the lungs. The most helpful information he received while learning GPB was to use his tongue in order to "squash" air into his lungs. He related GPB to making himself "burp," but instead of exhaling his "burp," he would force the air into his lungs. He rated the difficulty of learning GPB as 5 out of 10, where 10 is "very difficult." At the time of this writing, he was using GPB for 1 hour per day for transfers and dressing and sometimes for bathing.
He described using GPB to cough while he was on the ventilator by first using a ventilator breath, then a "sip of air" [GPB] followed by a cough before the next ventilator breath. After the patient had learned GPB, he was asked how GPB has helped him. He stated, "It has given me peace of mind when I'm off the ventilator. I feel safe, confident. Before, whenever I was off the ventilator, I was pretty scared. Now, I know I will be okay. I won't panic. I can keep a cool head."
| Discussion |
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TopAbstractIntroductionCase DescriptionInterventionGlossopharyngeal BreathingOutcomesDiscussionReferences |
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Several factors need to be considered when instructing patients to use GPB. Glossopharyngeal breathing is contraindicated for people who do not have normal vasomotor reflexes, because inspiration is prolonged and results in a high bronchial pressure, which decreases venous return to the heart and, in turn, causes low blood pressure.6,16,17 If low blood pressure occurs, the patient may complain of fullness in the head or feeling faint.17 To prevent this low blood pressure effect, the tidal volume should be maintained at 1,000 cc. In addition, if the time for taking the breath is not prolonged, then minimal blood pressure changes will occur. It is safe to take an occasional deep breath using GPB for coughing or chest stretching.6,16 If the patient has laryngeal irritation, learning GPB will be more difficult and may result in poor coordination and laryngeal spasm. Glossopharyngeal breathing is a voluntary activity and requires the individual to be awake.17 If patients have weakness of the anatomical structures used for swallowing, then they will have difficulty learning GPB because the same anatomical structures are used for both swallowing and GPB.
Glossopharyngeal breathing was a more effective breathing technique for this patient than NAMB. In my experience, several differences between GPB and NAMB explain why this patient and others may have more success learning one breathing technique over the other. First, NAMB is typically easier to learn because people are familiar with the use of these muscles for activities requiring strenuous breathing, such as running. Glossopharyngeal breathing may be more difficult to learn because it is not a natural method to breathe. Second, people with smaller body sizes will be more successful using NAMB than heavier people, who often have difficulty because the neck accessory muscles are not designed to support the body weight for respiration. The size of a person's body does not affect the ability to learn GPB. This may explain why children in some studies were able to learn NAMB.7,9 The patient in this case report weighed 86.2 kg, which may help to explain why he was more successful with GPB and learned it more easily than NAMB. Third, it does not matter where the ventilator is disconnected in order to use NAMB; however, a Passy-Muir valve or plugged tracheostomy is required for GPB to be effective. This is one reason why I believe therapists should consider offering training for both techniques to patients whenever possible.
All research to date involving people who are dependent on a ventilator and learn GPB has been done with individuals who have poliomyelitis and Duchenne muscular dystrophy. No published accounts of the use of GPB were found with people who are dependent on a ventilator because of tetraplegia secondary to a spinal cord injury. Because of the development of the Salk vaccine, fewer individuals have poliomyelitis today. As a result, fewer clinicians and patients know about GPB or how to learn and perform it. Glossopharyngeal breathing may have important application to patients today, and this technique should continue to be taught and used. Neck accessory muscle breathing is a common alternative breathing technique that also needs to continue to be used, but it does not allow the functional cough or chest expansion that GPB provides. Alternative breathing techniques may also benefit other patients with respiratory muscle paralysis, such as muscular dystrophy and Guillain-Barré syndrome.
Glossopharyngeal breathing was learned easily by people who had poliomyelitis by mere suggestion or demonstration and has been successfully taught to patients for the past 50 years at Rancho Los Amigos National Rehabilitation Center.5,6,11,13,17 It is possible that more people with respiratory muscle paralysis could learn GPB if they were made aware of it. People with poliomyelitis are living today who are able to perform GPB and from whom clinicians can learn.
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Adapted from a platform presentation at the Combined Sections Meeting of the American Physical Therapy Association, February 14–18, 1996, Atlanta, Ga; from a poster presentation at the Annual Meeting of the American Spinal Cord Injury Association, April 22–24, 1996, Seattle, Wash; and from an audiovisual presentation at the Scientific Meeting and Exposition of the American Physical Therapy Association, June 14–18, 1996, Minneapolis, Minn.
* Ferris Medical Ltd, 26 Lea Valley Trading Estate, Angel Rd, Edmonton, London, England NI8 3JD. 
Passy-Muir Inc, 4521 Campus Dr, Ste 273, Irvine, CA 92715.
Sontek Medical Inc, 20 Pond Park Rd, Hingham, MA 02043.
Puritan Bennett Corp, 2200 Fairaday, Carlsbad, CA 92008.
|| Datex-Ohmeda Inc, 1315 Century Dr, Louisville, CO 80027.
# Verimed, 101 NW 62nd St, Ste 212, Ft Lauderdale, FL 33309.
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