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Glossopharyngeal and Neck AccessoryMuscle Breathing in a Young AdultWith C2 Complete TetraplegiaResulting in Ventilator Dependency

Background and Purpose. This case report describes the use of glosso-pharyngeal breathing (GPB) and neck accessory muscle breathing(NAMB) in the treatment of an individual who was dependent on aventilator secondary to a spinal cord injury. Case Description. Thepatient was a 19-year-old man with C2 complete tetraplegia. Hereceived a 5-week inpatient program of GPB training 3 to 4 times perweek. A 4-week NAMB training program followed. Outcome. FollowingGPB training, forced vital capacity increased 35-fold, time off theventilator improved from 0 to 30 minutes, and a nonfunctional coughbecame a weak functional cough. After NAMB training, the patient wasable to be off the ventilator for 2 minutes. Discussion. Increasedventilatory capability has the potential to affect patients’ quality of lifeby improving cough function and decreasing dependence on a venti-lator in the event of accidental disconnection. [Warren VC. Glosso-pharyngeal and neck accessory muscle breathing in a young adult withC2 complete tetraplegia resulting in ventilator dependency. Phys Ther.2002;82:590–600.]

Key Words: Emergency breathing techniques, Glossopharyngeal breathing, Neck accessory muscle

breathing.

Valerie C Warren

590 Physical Therapy . Volume 82 . Number 6 . June 2002

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The number of people living today with spinalcord injuries who are dependent on a ventilatorhas increased due to improved intensive medi-cal support.1–3 One of the greatest fears of

people who are dependent on ventilators is becomingaccidentally disconnected from the ventilator.4 Glosso-pharyngeal breathing (GPB) and neck accessory musclebreathing (NAMB) are 2 alternative breathing tech-niques that these people can use in emergencies and topromote respiratory health.5–8

Glossopharyngeal breathing involves a series of gulpsusing the lips, tongue, pharynx, and larynx to pull airinto the lungs when the normal inspiratory muscles arenot functioning5 (Fig. 1). Glossopharyngeal breathingconsists of cycles of 6 to10 gulps of air followed byexhalation. Exhalation occurs when the glottis opensand the inflated lungs deflate passively due to the elasticrecoil of the lungs. In addition, GPB has been recom-mended to allow an individual to perform a functionalcough to clear tracheal secretions, increase the volumeof the speaking voice, and maintain chest wallmobility.9,10

People with high tetraplegia also can use the neckaccessory muscles to breathe in the event of ventilatordisconnection. Neck accessory muscle breathing usesmuscles such as the sternocleidomastoid and scalenus toaid in respiration (Fig. 2).

Glossopharyngeal breathing was discovered clinicallyand first documented in the medical literature by Dail in195111,12 when he observed a patient with poliomyelitiswho was dependent on a respirator “gulping air” whenhe was out of the respirator (iron lung) (Tab. 1). Thepatient had no movement of his diaphragm, yet was ableto increase his vital capacity from 250 cc to 600 cc withthe use of GPB. Vital capacity is the measurement of themaximum amount of air that can be exhaled after amaximal inspiration.

Although published reports of GPB programs have beenavailable since the 1950s,5,6,9–18 no literature describesan individual who is dependent on a ventilator second-ary to a spinal cord injury using GPB to breathe off theventilator to improve cough function or for chest expan-sion to maintain chest wall mobility. Researchers havereported that people who are dependent on a ventilatoras a result of poliomyelitis5,6,10,11,16,17 and Duchennemuscular dystrophy15 benefited from learning GPB.

VC Warren, PT, is Physical Therapist II, Rancho Los Amigos National Rehabilitation Center, 7601 E Imperial Hwy, Downey, CA 90242([email protected]).

The author thanks Rebecca Lewthwaite, PhD, Director of Research & Education, Rancho Los Amigos National Rehabilitation Center, for herassistance in editing the manuscript.

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.

This article was submitted February 21, 2001, and was accepted December 22, 2001.

Glossopharyngeal breathing is an

alternative breathing technique that

people who are dependent on

ventilators can use in emergencies and

to promote respiratory health.

Physical Therapy . Volume 82 . Number 6 . June 2002 Warren . 591

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Johnson et al15 presented a case study of a patient withDuchenne muscular dystrophy who was dependent on aventilator and able to quadruple his vital capacity withGPB. Using GPB, he could count to 25 with a vitalcapacity of 1,200 cc. He used GPB for up to 2 hours andwas able to vocalize. As his disease progressed, however,his vital capacity was reduced to zero, and he was unableto articulate a count of 1.

People who are dependent on a ventilator as the resultof a spinal cord injury, however, are different frompeople with poliomyelitis and Duchenne muscular dys-trophy because they usually have both sensory and motorloss of the muscles of respiration. People with polio-myelitis and Duchenne muscular have motor loss only.

Patients with spinal cord injuries who were not onventilators have been reported to learn GPB. Metcalf13

published the first study, which involved 23 adults withC4 to T1 complete tetraplegia. Using GPB, the subjects’

vital capacity increased to 81% of normal, they were ableto perform an effective cough independently, and theymaintained pulmonary compliance and thoracicmobility.

Montero et al14 described 14 people with C5 to C7complete tetraplegia, aged 15 to 37 years. Using GPB,the subjects added 700 to 1,000 cc of air to their vitalcapacity, a gain of 28% of normal. Overall, vital capacityincreased from 35% to 65% of normal. While perform-ing GPB, they were able to clear secretions from theirthroats and increase the loudness of their voices.

One report18 described an individual who was depen-dent on a ventilator secondary to a spinal cord injury andattempted to learn GPB, but did not succeed. Sheinstead learned to use her neck accessory muscles tobreathe when she was off the ventilator. Neck accessorymuscle breathing is the only reported emergency breath-ing technique taught to people who were dependent ona ventilator secondary to a spinal cord injury.7,8,18 Thesereports7,8,18 involved children and one adult.

Figure 1.Anatomy of structures used for glossopharyngeal breathing (GPB).Posterior mandibular dentition is where tongue touches during interven-tion of GPB. Reprinted with permission from Dail CW, Rogers M, GuessV, Atkins H. Glossopharyngeal Breathing. Downey, Calif: Los AmigosResearch & Education; 1979:5.

Figure 2.Muscles innervated for patients with high tetraplegia for use in neckaccessory muscle breathing.

592 . Warren Physical Therapy . Volume 82 . Number 6 . June 2002

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Gilgoff et al7 instructed 7 children with tetraplegia, aged2 to 16 years, who were dependent on a ventilator tosuccessfully breathe off their ventilators with neck mus-culature for 20 minutes to 2 hours. Morrison8 usedbiofeedback to teach a 30-year-old adult with C1 com-plete tetraplegia to use his neck accessory muscles tobreathe off a ventilator for 35 minutes. When thebiofeedback was removed, time off the ventilatordecreased to 7.5 minutes.

Donovan and Taylor18 described an 11-year-old girl withC2 complete tetraplegia who attempted to learn GPBover a 3-month period. The GPB program was discon-tinued because she developed use of her accessoryrespiratory muscle, the sternocleidomastoid, whichallowed her to breathe off the ventilator for up to 1 hour.She had a tidal volume of 50 to 100 cc and a respiratoryrate of 22 breaths per minute. She was also able to speak3 to 4 words per breath while off the ventilator. Twoyears later, she was able to breathe off the ventilator forup to 21⁄2 hours as she continued to strengthen heraccessory muscles by breathing off the ventilator 2 to 3times per day.

Many patients today who are dependent on a ventilatoras the result of spinal cord injuries might benefit fromlearning GPB and NAMB. In my opinion, both tech-niques are important for patients who are dependent onthe ventilator to learn because each has advantages anddisadvantages. Compared with NAMB, advantages ofGPB that I have observed include allowing the patient todevelop a larger vital capacity, which can be used tobreathe off the ventilator for a longer period of time orto produce a more productive cough to clear trachealsecretions. The disadvantages of GPB include beingmore difficult to learn and the need to close off theindividual’s tracheostomy by use of a Passy-Muir valve orcover the opening after accidental disconnection. If theperson becomes disconnected above the Passy-Muirvalve and the tracheostomy is open, GPB cannot be usedbecause the accumulated air escapes out of the trache-ostomy where the ventilator tubing was attached prior toaccidental disconnection. If this occurs, the individualmust rely on NAMB. In contrast to GPB, NAMB is easy tolearn and can be used as an emergency breathingalternative without concern for the site of disconnection.Small volumes of air can be generated to breathe off theventilator for a more limited time period, however, thanwith GPB. The heavier the individual, the greater thevital capacity and tidal volume needed to breathe off theventilator. In my experience, neck accessory musclescannot generate enough volume of air to allow heavierindividuals to breathe off the ventilator for longer thana few weeks. In addition, with NAMB each inhalation isindividually transmitted into the lungs, whereas withGPB several gulps of air are accumulated in the mouthbefore the volume of air is transmitted to the lungs.

Glossopharyngeal breathing has been taught to peopleusing several similar methods. Dail et al5 learned GPB bystudying fluoroscopy, cineflurography, spirography,pneumotachography, and airway pressure measure-ments and by examining patients and staff who hadlearned the technique. They reported that, of 100patients with poliomyelitis, 55 patients were taught GPBby hospital staff, 25 learned with minimal assistance ofothers, 15 learned from other patients, and 5 learned bythemselves without being aware of what they were doing.Patients have been taught GPB by first receiving anexplanation of GPB, then watching a movie or videotapeof someone performing GPB.9,15 Patients were trainedfor 30- to 60-minute sessions 3 to 5 days per week.9,15

The purpose of this case report is to describe a 5-weekprogram to teach of an adult male patient with C2complete tetraplegia to use alternative breathing tech-niques. The physical therapist and the physical therapistassistant taught the patient both GPB and NAMB.

Case Description

PatientThe patient was a 19-year-old man who was 188 cm (6 ft2 in) in height and weighed 86.2 kg (190 lb). He had C2complete tetraplegia secondary to a motor vehicle acci-dent, resulting in ventilator dependency. At the time ofhis injury, he was attending a local community collegefor an automotive repair program. He had been in bedfor approximately 21⁄2 months due to medical complica-tions at an acute care hospital prior to being admitted toa rehabilitation center as an inpatient.

ExaminationThe initial examination indicated that the patient wasfully dependent on the ventilator; had no diaphragmmovement, as indicated by manual palpation; and had anonfunctional cough.19 Cough function can be classifiedas “functional” when a person is able to clear all trachealsecretions independently, “weak functional” when a per-son is able to clear the throat and small amount ofsecretions 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 3mm of chest expansion at the xiphoid process17,20 and avital capacity17,21 of 75 cc when off the ventilator. Thevital capacity measurement was taken following thetesting procedure of the American Association for Respi-ratory Care Clinical Practice Guidelines21 with a hand-held Mark 14 Wright respirometer.*,22,23 Each time Imeasured the patient’s vital capacity, I used the same

* Ferris Medical Ltd, 26 Lea Valley Trading Estate, Angel Rd, Edmonton,London, England NI8 3JD.


method and recorded the highest of the 3 trials. I didnot determine the reliability of the measurements. Hisinitial ventilator settings were the following: tidal vol-ume: 800 cc, mode: assist control, rate: 14 breaths perminute, and fraction of inspired oxygen (Fio2): 30%. Hisblood gas values were: pH: 7.40, arterial partial pressureof oxygen (Pao2): 156 mm Hg, partial pressure of carbondioxide (Pco2): 35 mm Hg, bicarbonate (HCO3): 21,oxygen saturation: 99%, and Sigh: 1,200 cc. The patientwas placed on room air 22 days after the initial admis-sion. His Fio2 was decreased to 25% in the morning andto room air (21%) in the later afternoon. The ventilatorsettings remained unchanged.

To assess whether the muscles of respiration were inner-vated, manual muscle testing was performed.20 Thepatient had 4/5 strength of his upper trapezius, sterno-cleidomastoid, neck flexor, and neck extensor muscles.At the time he began the GPB and NAMB programs, hewas able to sit up daily in a chin-controlled, battery-powered wheelchair with supervision24 within the hospi-tal ward and contact/steady assistance when operatingthe wheelchair outside on unlevel terrain.

The power wheelchair involved use of the neck muscles,including the muscles of respiration. For example, thesternocleidomastoid muscle is used to assist with turningand backing up the wheelchair. This activity may havecontributed to strengthening his neck accessory muscles.In addition to physical therapy, he practiced using amouth stick device25 to assist with turning pages, oper-ating a telephone, and using a computer with his occu-pational therapist. This patient was able to learn newskills and information quickly, and he appeared to wantto learn as much as he could.

InterventionBased on this patient’s examination results (ie, unable tobreathe off ventilator, nonfunctional cough, and inner-vation of neck accessory muscles), intervention relatedto GPB and NAMB was selected. The patient wasinstructed in GPB prior to NAMB because, in my expe-rience, it is more difficult to teach GPB once the patienthas learned to breathe with neck accessory muscles.When NAMB is taught before GPB, it is difficult todetermine whether the patient is increasing inspiratoryvolume by using structures for GPB or neck accessorymuscles.

The patient began to learn GPB once he was able totolerate breathing with a nonfenestrated cuffless trache-ostomy and Passy-Muir valve.† First, the pulmonary phy-sician changed his tracheostomy from a nonfenestratedcuffed tube to a cuffless tube. The cuff was deflated 12

days after admission and was changed to a cufflesstracheostomy 4 days later. The ventilator settingremained the same as it was initially, except the Sighincreased from 1,100 cc at initial cuff deflation to 1,200cc with cuffless tracheostomy (Fig. 3).

A cuffed tracheostomy consists of a balloon or cuff thatinflates within the patient’s trachea. The cuffed trache-ostomy channels exhaled air between the lungs and thetrachea. Once the patient could tolerate the cuffedtracheostomy deflated, a cuffless tracheostomy was used.The cuffless tracheostomy does not have a cuff orballoon around the trachea. Therefore, exhaled air canescape up to the vocal folds and sometimes allow thepatient to speak. This patient was able to vocalize withthe cuffless tracheostomy. The cuffless tracheostomy isnecessary for safe use of the Passy-Muir valve.26

† Passy-Muir Inc, 4521 Campus Dr, Ste 273, Irvine, CA 92715.

Figure 3.Airflow with cuffed and cuffless tracheostomy tube. With cuffed trache-ostomy tube, inhaled air travels through nonfenestrated tracheostomytube into the lungs, exhaled air travels only out of nonfenestratedtracheostomy tube, and patient is unable to vocalize. With cufflesstracheostomy tube, inhaled air travels through nonfenestrated tracheos-tomy tube into the lungs; exhaled air travels around tracheostomy tube,passes over the vocal cords, and exits from nose and mouth; and patientis able to vocalize.

Figure 4.Setup for breathing with mouth positive air in preparation for learningglossopharyngeal breathing.


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The Passy-Muir valve is a one-way valve that is placedbetween the Bodai tracheostomy adapter‡ and mechan-ical flex-tubing (Flex tube§) when used in conjunctionwith the ventilator. The Bodai tracheostomy adapter isused because it provides easy access for suctioning and iscomfortable for the patient. When the ventilator tubingis moved there is less pressure on the stoma because theBodai tracheostomy adapter rotates on the tracheostomy(Fig. 4).

Several days after the patient was given the cufflesstracheostomy, the goal was to have him wear the Passy-Muir valve until he felt comfortable for most of the day.Passy-Muir valve tolerance was achieved with the assis-tance of the patient’s speech pathologist and was accom-plished in 2 days. When the Passy-Muir valve is used, airis directed out of the patient’s mouth during exhalation.The speech pathologist initially monitored the patientusing a pulse oximeter to ensure that his oxygen satura-tion level did not drop below 90% of normal and that hewas comfortable while using the Passy-Muir valve. Thespeech pathologist assisted the patient in coordinatinghis breathing while using the Passy-Muir valve. Prior touse of the Passy-Muir valve, the patient would speakupon inhalation. With the use of the Passy-Muir valve,the patient used exhalation to speak. The ventilatorsettings did not change with the use of the Passy-Muirvalve.

The Passy-Muir valve allows the inhaled air from theventilator to fill the patient’s lungs, but does not allowthe exhaled air to flow out through the tubing forexpiration. Instead, the expired air is directed outthrough the nose and mouth. During inhalation, thePassy-Muir valve prevents air from escaping out throughthe tracheostomy tubing and directs it into the lungs.The Passy-Muir valve also directs air past the vocal cordsfor speaking during exhalation. The manufacturer statesthat inflation of the patient’s cuffed tracheostomy whenthe Passy-Muir valve is in place would cause suffocationbecause the air the patient receives from the ventilatorwould be trapped between the lungs and the Passy-Muirvalve,26 which is why a cuffless tracheostomy is used withthe Passy-Muir valve.

Glossopharyngeal BreathingPrior to starting the GPB training sessions, the patientwas shown a videotape of a therapist explaining GPB anda person who was dependent on a ventilator performingGPB. The patient began the first week of the 5-weekprogram learning how to breathe with the ventilator airin his mouth instead of his tracheostomy (Figs. 4 and 5).

This was accomplished by attaching a mouthpiece(Calox§) to the ventilator tubing at the level where thetubing attaches to the trachea adapter. The patientwould then accept air from the ventilator into his mouthinstead of into his trachea. The ventilator settings werenot changed from those set when the air enteredthrough his tracheostomy. This manner of breathingwith the ventilator mouthpiece will be referred to asmouth positive air.

To prevent the air coming into his mouth from escapingthrough the trachea where it attaches to the flex-tubing,a Passy-Muir valve was put in place between the Bodaitracheostomy adapter and the mechanical flex-tubing.The patient wore the Passy-Muir valve whenever GPBtraining occurred. While the patient used the air tobreathe from his ventilator into his mouth, he learned 2primary skills necessary for learning GPB. First, helearned how to close off his nasopharynx as he inhaledthe air coming into his mouth from the ventilator. Iplaced a mirror under the patient’s nose. If the mirrordid not fog during inhalation, then the patient wasachieving adequate closure of his nasopharynx. Thesecond skill was to ensure that the patient’s chest wasrising during inhalation while he received air into hismouth from the ventilator. The patient’s chest risingduring inhalation indicated that the air was going intohis lungs. By the end of the first week, the patient wasable to breathe comfortably for 5 minutes with theventilator delivering air into his mouth.

The second week involved teaching the patient 3 addi-tional exercises that are similar to performing GPB.These exercises were taught while the patient usedmouth positive air.

‡ Sontek Medical Inc, 20 Pond Park Rd, Hingham, MA 02043.§ Puritan Bennett Corp, 2200 Fairaday, Carlsbad, CA 92008.

Figure 5.An additional 100-cc flex-tubing is attached to mouthpiece to allow forquick reconnection.


The first exercise involved having the patient take abreath of mouth positive air, close his glottis to keep theair in his lungs, open his mouth, pause, then exhale theair by making an “ahhhhhh” sound. This exercise wasintended to help the patient to learn how to open andclose his glottis.

The second exercise taught him how to open and closehis vocal cords quickly to close his glottis for alveolar gasexchange. When a gulp of air is taken into the pharynxduring GPB, the vocal cords need to be opened andclosed quickly to trap air below the glottis and the lungs.He performed this second exercise by taking a breath ofmouth positive air, closing his glottis to keep the air inhis lungs, opening his mouth, pausing, then exhaling byquickly starting and stopping the flow of air whilemaking a sharp “ah, ah, ah” sound until all of the breathof air was exhaled. He was instructed to make this soundquickly and staccato-like.

The third exercise was intended to help the patient tolearn to depress and elevate his larynx while holding airin his closed glottis. This involved taking a breath ofmouth positive air, closing the glottis, opening hismouth, and then depressing and elevating the posteriorportion of his tongue several times while the tip of thetongue maintained contact behind the posterior lowerdentition. Then he exhaled the air held below his glottis.

By mimicking the physical therapist and occasionallywatching himself in the mirror, the patient was able toperform a GPB stroke (steps 1–4 in Tab. 2). He wasinstructed 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 exercisesand never dropped below 97% of normal.

During the third week of GBP training, the patientcontinued to practice and became more efficient usingGPB. He discovered one night while using GPB as hisnurses transferred him to his bed that he no longerneeded to make an “up” sound or exaggerate with hislips, to perform GPB. He reported feeling less fatigue inhis jaw and therefore an ability to perform GPB longer.Using GPB in this way, he was able to breathe off theventilator for 2 minutes with a vital capacity of 1,600 ccand oxygen saturation level at 98% and above. Thepatient’s oxygen saturation level was monitored by anOhmeda Biox 3700 pulse oximeter�,27 whenever he wasdisconnected from the ventilator, and vital capacity wasmeasured with a Wright respirometer.

The patient had mastered the GPB stroke by the fourthweek. He had a vital capacity of 2,000 cc after 22 minutesoff the ventilator with oxygen saturation at 96% andabove. At this point, I compared the patient’s chestexpansion with the ventilator with expansion while usingGPB off the ventilator. He was able to expand his chest,measured at the xiphoid process, 9 mm with GPB off theventilator compared with 3 mm with the ventilatoralone. In addition, he was able to perform a weakfunctional cough both on and off the ventilator usingGPB. A weak functional cough would allow him to clearsome tracheal secretions independently.19 He accom-

� Datex-Ohmeda Inc, 1315 Century Dr, Louisville, CO 80027.

Table 2.Steps 1 Through 4 for Physiology of One Glossopharyngeal Breathing(GPB) Stroke

Step 1: Air enters oral pharynx (concurrent events)Mouth opens; air enters as patient reaches out with lips

roundedPharynx is widened to allow more room for air to enterFloor of mouth, larynx, and tongue depressTongue flattens and the tip touches posterior mandibular

dentitionGlottis is closed

Step 2: Air is trapped in oral pharynxPatient shapes lips as if to say “oop” but instead makes

an “up” sound just before lips closeLips close and trap air in the pharynx while the glottis

remains closedCheeks compress

Step 3: Air enters lungsLips remain closedSoft palate, floor of mouth, larynx, and dorsum of

tongue elevate as the tongue sequentially rolls topropel air into the pharynx

Pharynx constricts, glottis opens, and air passes into thelarynx

Step 4: Air is trapped in the lungsGlottis immediately closes, trapping the air in the

trachea and lungs as a result of prior stepsProcedure is repeated 8–12 timesAccumulated air is exhaled by immediate opening of

the glottis

Figure 6.Time off ventilator while learning glossopharyngeal breathing improvedfrom 0 minutes at week 1 to 30 minutes at week 5.


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plished this cough by first holding a breath from theventilator in his lungs, then performing GPB, andcoughing just prior to the next ventilator breath. Hisvital capacity with coughing was 3,000 cc.

After 5 weeks of GPB training 3 to 4 times per week for20- to 30-minute sessions with the physical therapist orphysical therapist assistant, the patient was able to useGPB to breathe off the ventilator for 30 minutes (Fig. 6).

The patient may have been able to breathe longer off theventilator, but 30 minutes was deemed adequate by thepatient and the physical therapist as this would allowadequate time for assistance in the event he was acciden-tally disconnected from the ventilator. His vital capacitywas 2,650 cc (Fig. 7).

He could perform a weak functional cough to cleartracheal secretions, and his chest expanded 9 mm at thexiphoid process. A respiratory therapist did a blood gasanalysis as the patient performed GPB off the ventilator

for just over 30 minutes. His blood gases were normal(Tab. 3).

After the patient mastered GPB, I instructed him inNAMB. The primary neck accessory muscles that hecould use were the sternocleidomastoid and scalenus.Strengthening exercises for the neck accessory musclesincluded manual resistance from the therapist and useof mouth sticks, and operating a chin-controlled powerwheelchair. Neck strengthening exercises were per-formed with the patient by the physical therapist assis-tant 3 to 5 times per week during the entire inpatientprogram. The exercises were resistive throughout rangeof motion and isometric with 5-second hold resistanceprovided to the patient’s head by the physical therapistassistant’s hand to strengthen the neck flexors, necklateral flexors, and neck extensors and with neck flexionwith rotation to isolate the sternocleidomastoid muscles.Immediately after the patient successfully completed theGPB training program, he began NAMB off the ventila-tor with the use of biofeedback. The Verimed Myoexer-ciser biofeedback machine# was used with 2 electrodesattached to each sternocleidomastoid muscle to visuallyshow the patient how to use these muscles for respira-tion. The first day, he remained on the ventilator for afew minutes while using the biofeedback to practicebefore being disconnected from the ventilator. Next,while using the biofeedback, he was taken off theventilator and he performed NAMB until his oxygensaturation level dropped below 90% of normal. This wasrepeated several times during each training session.Biofeedback sessions were held 4 or 5 times per week for20 to 30 minutes per session.

After 4 weeks of training, the patient was able to use hisneck accessory muscles to breathe off the ventilator for 2minutes before his oxygen saturation level droppedbelow 90% of normal. Further training was discontinuedbecause the patient was frustrated with his lack ofprogress.

OutcomesAfter 5 weeks of GPB training 3 to 4 times per week, thepatient was able to perform GPB off the ventilator for 30minutes (Fig. 6) with a vital capacity of 2,650 cc (Fig. 7).His cough improved from nonfunctional to weak func-tional, which allowed him to clear tracheal secretions.He could take a deep breath and expand his chest from3 mm with the ventilator alone to 9 mm using GPB.

The patient was only able to use NAMB for 2 minutesbefore his oxygen saturation level dropped below 90% ofnormal. After 4 weeks, training to breathe with neck

# Verimed, 101 NW 62nd St, Ste 212, Ft Lauderdale, FL 33309.

Table 3.Blood Gas Values While Breathing Off the Ventilator for 30 MinutesUsing Glossopharyngeal Breathinga

Patient’sValues

NormalRanges

pH 7.37 7.35–7.45PCO2 44 mm Hg 38–50 mm HgPaO2 91 mm Hg 83–108 mm HgHCO3 25 mmol/L 22–29 mmol/LStandard base excess 0 mmol/LOxygen saturation 97% 95%–99%

a Pco2�partial pressure of carbon dioxide, Pao2�arterial partial pressure ofoxygen, HCO3 � bicarbonate.

Figure 7.Vital capacity using glossopharyngeal breathing measured over 5-weekperiod increased from 0 cc at week 1 to 2,650 cc at week 5.


accessory muscles was discontinued because the patientbecame frustrated with his lack of progress.

The patient was discharged from the rehabilitationcenter to a residential home that provided 24-hournursing care. While at this home, he was encouraged bythe nursing staff to continue to practice NAMB off theventilator. The patient stated that he was able to breatheoff the ventilator with his neck accessory muscles for 4minutes at a time after living at the residential home for2 years. He rated difficulty in learning to use his neckaccessory muscles to breathe off the ventilator as 9 out of10, where 10 is “very difficult.”

I interviewed the patient by telephone 4 years after hisinpatient rehabilitation program. He was living in hisown home with 24-hour nursing care while attendingcollege to obtain a degree in computer science. Whenasked to recall his experience learning GPB, he com-mented that he knew he was getting air into his lungswith GPB because he could see his chest rising and hisribs expand. He explain that he used counting as amethod to pace himself to ensure he would not breathetoo rapidly, become anxious, and then become tiredwhen using GPB to breathe off the ventilator. He wouldexhale once he had a feeling he could not accommodatefurther breaths. He reported that the easiest portion ofperforming GPB is pushing the air into the lungs. Themost helpful information he received while learningGPB was to use his tongue in order to “squash” air intohis lungs. He related GPB to making himself “burp,” butinstead of exhaling his “burp,” he would force the airinto his lungs. He rated the difficulty of learning GPB as5 out of 10, where 10 is “very difficult.” At the time of thiswriting, he was using GPB for 1 hour per day fortransfers and dressing and sometimes for bathing.

He described using GPB to cough while he was on theventilator by first using a ventilator breath, then a “sip ofair” [GPB] followed by a cough before the next ventila-tor breath. After the patient had learned GPB, he wasasked how GPB has helped him. He stated, “It has givenme peace of mind when I’m off the ventilator. I feel safe,confident. Before, whenever I was off the ventilator, Iwas pretty scared. Now, I know I will be okay. I won’tpanic. I can keep a cool head.”

DiscussionRespiratory complications and the potential for acciden-tal disconnection from the ventilator are life threateningto individuals with high tetraplegia who are dependenton ventilators to breathe. In addition to reducing fearand anxiety, emergency breathing techniques provide apotentially life-saving alternative breathing method inthe event of ventilator disconnection and may reduce

the risk of respiratory complications by allowing a morefunctional cough.

Several factors need to be considered when instructingpatients to use GPB. Glossopharyngeal breathing iscontraindicated for people who do not have normalvasomotor reflexes, because inspiration is prolongedand results in a high bronchial pressure, which decreasesvenous return to the heart and, in turn, causes low bloodpressure.6,16,17 If low blood pressure occurs, the patientmay complain of fullness in the head or feeling faint.17

To prevent this low blood pressure effect, the tidalvolume should be maintained at 1,000 cc. In addition, ifthe time for taking the breath is not prolonged, thenminimal blood pressure changes will occur. It is safe totake an occasional deep breath using GPB for coughingor chest stretching.6,16 If the patient has laryngeal irrita-tion, learning GPB will be more difficult and may resultin poor coordination and laryngeal spasm. Glossopha-ryngeal breathing is a voluntary activity and requires theindividual to be awake.17 If patients have weakness of theanatomical structures used for swallowing, then they willhave difficulty learning GPB because the same anatom-ical structures are used for both swallowing and GPB.

Glossopharyngeal breathing was a more effective breath-ing technique for this patient than NAMB. In my expe-rience, several differences between GPB and NAMBexplain why this patient and others may have moresuccess learning one breathing technique over theother. First, NAMB is typically easier to learn becausepeople are familiar with the use of these muscles foractivities requiring strenuous breathing, such as run-ning. Glossopharyngeal breathing may be more difficultto learn because it is not a natural method to breathe.Second, people with smaller body sizes will be moresuccessful using NAMB than heavier people, who oftenhave difficulty because the neck accessory muscles arenot designed to support the body weight for respiration.The size of a person’s body does not affect the ability tolearn GPB. This may explain why children in somestudies were able to learn NAMB.7,9 The patient in thiscase report weighed 86.2 kg, which may help to explainwhy he was more successful with GPB and learned itmore easily than NAMB. Third, it does not matter wherethe ventilator is disconnected in order to use NAMB;however, a Passy-Muir valve or plugged tracheostomy isrequired for GPB to be effective. This is one reason whyI believe therapists should consider offering training forboth techniques to patients whenever possible.

All research to date involving people who are dependenton a ventilator and learn GPB has been done withindividuals who have poliomyelitis and Duchenne mus-cular dystrophy. No published accounts of the use ofGPB were found with people who are dependent on a


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ventilator because of tetraplegia secondary to a spinalcord injury. Because of the development of the Salkvaccine, fewer individuals have poliomyelitis today. As aresult, fewer clinicians and patients know about GPB orhow to learn and perform it. Glossopharyngeal breath-ing may have important application to patients today,and this technique should continue to be taught andused. Neck accessory muscle breathing is a commonalternative breathing technique that also needs to con-tinue to be used, but it does not allow the functionalcough or chest expansion that GPB provides. Alternativebreathing techniques may also benefit other patientswith respiratory muscle paralysis, such as muscular dys-trophy and Guillain-Barre syndrome.

Glossopharyngeal breathing was learned easily by peoplewho had poliomyelitis by mere suggestion or demonstra-tion and has been successfully taught to patients for thepast 50 years at Rancho Los Amigos National Rehabili-tation Center.5,6,11,13,17 It is possible that more peoplewith respiratory muscle paralysis could learn GPB if theywere made aware of it. People with poliomyelitis areliving today who are able to perform GPB and fromwhom clinicians can learn.

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2 Carter RE. Experience with ventilator dependent patients. Paraplegia.1993;31:150–153.

3 DeVivo MJ, Ivie CS III. Life expectancy of ventilator-dependentpersons with spinal cord injuries. Chest. 1995;108:226–232.

4 Clark K. Psychological aspects of prolonged ventilator dependency.Respiratory Care. 1986;31:329–333.

5 Dail CW, Affeldt JE, Collier CR. Clinical aspects of glossopharyngealbreathing. JAMA. 1955:158:445–449.

6 Affeldt JA, Dail CW, Collier CR, Farr AF. Glossopharyngeal breath-ing: ventilator studies. J Appl Physiol. 1955;8:111–113.

7 Gilgoff IS, Barras DM, Jones MS, Adkins HV. Neck breathing: a formof voluntary respiration for the spine-injured ventilator-dependentquadriplegic child. Pediatrics. 1988;8:741–745.

8 Morrison SV. Biofeedback to facilitate unassisted ventilation inindividuals with high-level quadriplegia: a report. Phys Ther. 1988;68:1378–1380.

9 Clough P. Glossopharyngeal breathing: its application with a trau-matic quadriplegic patient. Arch Phys Med Rehabil. 1983;64:384–385.

10 Mazza FG, DiMarco AF, Altose MD, Strohl KP. The flow-volumeloop during glossopharyngeal breathing. Chest. 1984;85:638–640.

11 Dail CW. “Glossopharyngeal breathing” by paralyzed patients: apreliminary report. Cal Med. 1951;75:15–25.

12 Dail CW, Rogers M, Guess V, Atkins H. Glossopharyngeal Breathing.Downey, Calif: Los Amigos Research & Education; 1979.

13 Metcalf VA. Vital capacity and glossopharyngeal breathing in trau-matic quadriplegia. Phys Ther. 1966;46:835–838.

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15 Johnson EW, Reynolds HT, Stauch D. Duchenne muscular dystro-phy: a case with prolonged survival. Arch Phys Med Rehabil. 1985;66:260–261.

16 Collier CR, Dail CW, Affeldt JE. Mechanics of glossopharyngealbreathing. J Appl Physiol. 1956;8:580–584.

17 Zumwalt M, Adkins HV, Dail CW, Affeldt JE. Glossopharyngealbreathing. Phys Ther Rev. 1956;36:455–460.

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19 Alvarez SE, Peterson A, Lunsford BR. Respiratory treatment of theadult patient with spinal cord injury. Phys Ther. 1981;61:1737–1745.

20 Hislop HJ, Montgomery J. Daniel’s and Worthingham’s Muscle Testing:Techniques of Manual Examination. 6th ed. Philadelphia, Pa: WB Saun-ders Co; 1995.

21 American Association of Respiratory Care Clinical Practice Guide-lines. Respir Care. 1996;41:629–636.

22 Wright Respirometer Operating Instructions. Edmonton, London,England: Ferraris Development & Engineering Co Ltd.

23 Daykin AP, Nunn GF, Wright BM. The measurement of vitalcapacity and minute volume with the Wright respirometer. Br J DisChest. 1978;72:333–335.

24 Guide for the Uniform Data Set for Medical Rehabilitation: Including theFunctional Independence Measure, Version 5. Buffalo, NY: UB FoundationActivities Inc; 1996.

25 Kovich K, Presperin J. Communication. In: Hill JP, ed. Spinal CordInjury: A Guide to Functional Outcomes in Occupational Therapy. Gaithers-burg, Md: Aspen Publishers Inc; 1986:95–105.

26 Passy PE, Muir DA. Passy-Muir Tracheostomy and Ventilator SpeakingValves Instruction Booklet. Irvine, Calif: Passy-Muir Inc; 1989.

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