Respiratory muscle strength training (RMST) to facilitate swallow and pulmonary rehabilitation in critical care patients with severe deconditioning: A case series

Ms Caroline Nicholls1,2,3, Prof Elizabeth Ward2,4, Ms Caroline Nicholls1, Ms Rosemarie Giannone1, Ms Katina Skylas1, Prof Peter Maitz1,5

1Concord Repatriation General Hospital, Concord, Australia, 2School of Health and Rehabilitation Services, University of Queensland, St Lucia, Australia, 3Faculty of Health Sciences, University of Sydney, Camperdown, Australia, 4Centre for Functioning and Health Research, Queensland Health, Buranda, Australia, 5Faculty of Medicine, University of Sydney, Camperdown, Australia

Background: ICU acquired deconditioning can result in impaired respiratory and swallow function. Respiratory Muscle Strength Training (RMST) can improve cough and swallowing outcomes, however its use to rehabilitate swallowing in critical care has not been evaluated.

Aim: Examine the effect of RMST on respiratory and swallow function in 2 critical care patients with marked deconditioning post severe tissue loss.

Methods: Case study design. Case-1, 19-year-old male with 80% burns; Case-2, 45-year-old male with GAS myositis necessitating quadruple amputation. Both required prolonged intensive care and mechanical ventilation. Both had chronic aspiration despite routine intensive pulmonary and dysphagia rehabilitation. At 25 and 26 weeks post injury for Case 1 and 2, RMST was employed using EMST150 and Threshold-IMT devices. At baseline and throughout treatment, data collected included peak expiratory flow (PEF), anthropometry measures, aspiration risk (PAS), pharyngeal clearance (Yale), secretions (NZSS) and functional diet (FOIS) via endoscopy.

Results: At baseline, Case-1 PEF score was 41% and Case-2 PEF 14% predicted (age-height norm), indicating severe expiratory compromise. Both had extreme energy requirements (3300kcal/day; 3500kcal/day). Baseline swallowing scores were: PAS-8,8; Yale-9,10; NZSS-4,7; FOIS-1,1 respectively, indicating profound dysphagia. At weeks 3/7 respectively of RMST, swallow function improved to allow safe oral intake (FOIS-3), followed by tracheostomy decannulation. At weeks 10/11, full dysphagia resolution was achieved (FOIS-7; PAS-1, Yale-2, NZSS-0), with PEF at 70% and 48% predicted. Both patients continued RMST and by discharge from the acute facility, PEF was 84% and 80% predicted.

Conclusion: RMST was viable and assisted swallow and pulmonary rehabilitation, in both critical care cases with profound deconditioning.


Caroline Nicholls is the Senior Burns Dietitian at Concord Hospital in Sydney. She is well recognised for her expertise in the field of nutrition support and clinical research, especially in severe burn injury.

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