Case #1: Patient is an 85 year old female with Parkinson's Disease. The patient was not audible enough to be understood nor could she speak one or two short words without taking another breath. Resistance breathing training was initiated the first week of therapy. RBT challenged the patient to improve breath support. Her inhalation baseline was approximately 2 seconds and exhalation approximately 2.5 seconds. After the third week of therapy the patient's endurance had improved. Inhalation was approximately 3 seconds and exhalation was 4 seconds. Her conversational speech improved to an audible 2-3 words. The patient plateaued with inhalation approximately 4.5 seconds and exhalation approximately 5 seconds. She was placed on a restorative program for continuation with the Breather. I feel there is a great need to strengthen the respiratory muscles since they significantly support speech.
- Lynn Patterson, Speech Pathologist, Aurora, CO.
Case #2: We were not seeing progress with typical therapy strategies in this 5 year old child with very poor volume and breathy voice quality in addition to hypernasality and nasal air emission during connected speech until we introduced the Breather. We began using the Breather with the lowest resistance level for both inhalation and exhalation, gradually increasing to the highest resistance levels over a five week period of therapy. Voicing volume improved and nasal air emissions have decreased in connected speech. She enjoys using her special “Blue Blower.” The family practices with the Breather one to two times a day, in addition to more typical speech carry over activities.
- Debra Beckman, MS,CCC-SLP
Beckman & Associates, Winter Park, FL
Case #3: The patient is a 91 year old male who recently suffered a stroke. He had uncoordinated respiratory skills and decreased audible sounds. The patient had a cognitive deficit but could understand the sequencing needed to control breathing while practicing RBT with the Breather. The patient is utilizing RBT due to flaccid dysarthria, a speech disorder common after a stroke, and dysphagia, also common after a stroke. Breath support for speech and swallowing has improved slightly and the patient's goal is to improve inhalation and exhalation in increments of 2 seconds and to improve swallowing.
- Rationale for utilization of RBT for speech therapy: 1. It helps the clinician fabricate measurable goals. 2. It's a tangible means of teaching appropriate breathing. 3. Provides a way of giving muscular resistance. 4. Improves lung capacity for longer sentence structure and audible sound.
- Lynn Patterson, Speech Pathologist, Aurora, CO
- Jenny Little, Speech-Language Pathologist, Merritt Island, FL
Case #5: Pat is a 65 y/o female with m. sclerosis (MS) with a severe remission episode causing hospitalization, PEG tube placement and NPO status upon admission to SNF. She also had periodic dysarthria. She was seen 5 d/wk using Deep Pharyngeal Neuromuscular Stimulation (DPNS) and resistive breathing training (RBT) with the Breather. By the time she left the SNF 6 weeks later, she was eating regular texture and drinking thin liquids. However, her voice was weak, tremulous and often was dysphonic. She was seen via SLP home health visits. She was given voice TX and the RBT was continued at 90 RBT cycles/day. After 4 wks of treatment, her voice returned to prior level and was completely understandable to family and staff at assisted living facility. At d/c, she and the family agreed to continue on a RBT maintenance schedule of 2 sets or 60 TX cycles/day.
- David Griffith, M.S. CCC Speech-Language Pathologist, Boise, ID
- David Griffith, M.S. CCC Speech-Language Pathologist, Boise, ID
- David Griffith, M.S. CCC Speech-Language Pathologist, Boise, ID
- David Griffith, M.S. CCC Speech-Language Pathologist, Boise, ID
Case #9 is quite dramatic. A respiratory therapist who works very closely with speech, OT & PT shared this success story. His patient is a 23 year old male that was a post ventilator patient as well as a very long post tracheostomy patient due to an ultra-light plane crash approximately one year earlier. Diagnosis was a CVA secondary to the severe head trauma. He'd been on the ventilator for months and more than once the family had been pleaded with to turn off the ventilator. He was also a double amputee due to the crash. He began seeing this patient 3 times per week at his home. OT and PT had already been initiated, but they were having difficulty progressing due to his limited respiratory status. Although his lungs were clear, his posterior breath sounds were diminished. His minute volume was 8 L and TV was 500 ml. And after many attempts, his NIF or MIP averaged -18 to -20 cmH20. And his maximum airway pressure, MEP, was +20 cmH20. This, of course, is quite low for a young person. Plans were to initiate both inspiratory and expiratory resistive breathing training (RBT) with the Breather and to use therabands for upper body conditioning. RBT was done in sets. That is inhaling and exhaling with resistance approximately 1 to 2 minutes, then resting as necessary, then repeating the set. After seven sessions, the patient's father told the therapist that he could notice quite a bit of difference in his son's voice sounds at different times, and by nine sessions even more people commented on improved voice. The patient also had difficulty in swallowing. He'd been tube fed to maintain nutrition, but was encouraged to try and drink as much as possible. The therapist had been informed that the patient's ability to swallow had been improving since working with RBT, and after approximately 11 RBT sessions, the patient was able to swallow approximately 4 ounces at a time with apparently no complications - aspiration. The patient's status continued to improve over the course of the next 4 months; the other therapists expressed it was easier to work with the patient due to his improved respiratory status. It was noted, however, by his mother that if her son didn't regularly practice RBT, that his swallowing appeared to be more difficult. So more emphasis was placed on regular training. After six months of training, the patient's physician felt the feeding tube could be removed if the patient could consistently tolerate 45 ounces of liquid per day. In this period of training, the patient's working inspiratory resistances increased from - 4 to - 6 cmH20 to a consistent -10 to -12 cmH20 and expiratory resistances increased from 2 to 4 cmH20 to 12 to 20 cmH20. His improved swallowing seemed to dramatically coincide with the increased working expiratory resistances over the past month. The patient's cough was also much stronger due to increased abdominal strength. By 8 months his NIF or MIP was - 60 cmH20; MEP +58 cmH20. Recall they were each only 18 to 20 negative and positive cmH20 respectively when therapy had begun. The patient's physical therapist also was able to become more aggressive with therapy. This was essential because he had been fitted with prostheseses. The patient consistently improved, and 2 years after his accident, he went out dancing even though he had to use a walker. The patient is still being seen by the therapist at his private outpatient rehab facility in Boonville, MO.
Resistive Breathing Training (RBT). . .
An Additional Treatment For Pharyngeal Dysphagia
by David L. Griffith, M.S. CCC Speech-Language Pathologist
Note from PN Medical: The following is one speech pathologist's technique for using the Breather; there are many more. Please let us know how you use the Breather.
The patient with pharyngeal dysphagia has weak and often uncoordinated muscles and/or nerve function in the oral-pharyngeal areas. I have found two methods of treatment to be highly effective: Both may be considered somewhat nonconventional to some, but I have found two methods of treatment to be highly effective: Resistive Breathing Training (RBT) and Deep Pharyngeal Neuromuscular Stimulation (DPNS). DPNS are TX methods taught by The Speech Team, Inc., utilizing frozen lemon glycerin swabs to stimulate areas of the palate, tongue, and pharyngeal constrictor muscles. DPNS stimulates the muscle-nerve response patterns and facilitates return to normal swallow function. RBT TX is performed by using the Breather, provided by PN Medical. RBT strengthens oral-pharyngeal muscles by resistive breathing exercises.
When RBT and DPNA can be used as a combination treatment, the best results have occurred. I train the patient to use the RBT Breather at 90 RBT cycles/day and provide the DPNS TX to patients @ 60 stims/sessions. If a patient is absolutely resistance to DPNS, the RBT TX can be used as a single "stand alone" TX for pharyngeal dysphagia.
To use RBT effectively, a patient needs enough cognition to follow simple directions. I usually joke with them by telling them: "This is going to do three things for you: make you smarter by getting more oxygen to your brain, increase your lung capacity, and strengthen your throat muscles so you can swallow better."
The Breather has differing resistances for inhalation & exhalation. The resistances are usually started at #1 or #2 for inspiration. One RBT cycle is a quick, forceful inhalation - a 2-3 second pause where the patient is asked to "hold it" - then a quick forceful exhalation. These are done in 3 sets of 10 with a 1-2 minute resting cycle in between sets. My criteria for increasing resistance is when the patient can perform 27/30 cycles with full force. Goal: Use maximum possible resistance to give maximum strength. Resistance will vary, but most can reach #4 in and #3 out.
To assure patient compliance with both the pacing and amount of RBT cycles, I provide a cassette tape that they play every time they do a set of 30 cycles. The tape is made while the patient performs the RBT. This allows for pacing for individual patient differences. The instructions on the training tape are: 1. A greeting: "Good morning, afternoon, and evening (They are asked to complete before/after each meal.) 2. Instruction: "Now suck in a quick breath" (I make a sucking in sound on the tape.) "And hold it - hold it - hold it. (2-3 seconds) "Now blow out hard and fast." (I make a blowing sound into the tape.) 3. Continue instructions with #s. "Good. Now here comes # 2-10) 4. 1-2 minute rest - "Now you can put your Breather down and just relax for a full minute." (This is timed and music can be played into the tape or positive statements can be made about the patient or the treatment effectiveness, etc. - something to pass the time.) 5. Two additional sets - "All right, you've had a great rest. Now let's do another set of 10." (Repeat the instructions of 2 - 4 above.) 6. Final instructions: "Great, you've just completed all 3 cycles. Please put a check mark on your chart." (Allow time for them to mark their chart, date columns with space for 3 checks.) "Good, now turn off the tape recorder and rewind the tape." If you think the patient may forget to turn off/rewind, wait 30 seconds and say: "If you can still hear my voice, you forgot to turn off the tape and rewind."