RMST TOP 10 by NYUMC

1.  Patients are too sick to begin Respiratory Muscle Strength Training (RMST) in the acute medicine setting:  If you’re sick or weak… You Need Rehab! 

• • Chat it up! We are masters of communication, after all. Address questions, concerns, and misconceptions regarding the use of RMST.
  • Get 15 seconds of fame on rounds, and make it count.
  • No reason to re- invent the wheel! Guidelines, including contraindications and considerations from Aspire, exist and are readily available for those in doubt. Visit www.emst150.com.
  • Trachs, chest tubes, and pain, oh my! Considering RMST with Intensive Care Unit (ICU) level, patients may feel scared initially, but research would beg to differ! These patients may benefit most from respiratory intervention. Early mobility of respiratory muscles is essential for recovery.
  • Impaired communication is a driving factor for both anxiety and delirium. RMST enhances the effectiveness of communication and can alleviate these symptoms.

 

2.  Infection control precautions are an insurmountable barrier to beginning Expiratory Muscle Strength Training (EMST): Nah, this is 2023. We have it down pat by now!

• • • With the recent COVID-19 pandemic, infection control has been a hot topic. Here are some infection control considerations when beginning an RMST program:
    • Devices are for patient use. They do not need to be wiped down and shared amongst patients. The EMST devices and their mouthpieces may be cleaned with warm soap and water.
    • Manometry can be excluded if the patient has an infection that can contaminate surfaces. In these cases, the starting pressure threshold can be determined and modified based on effort and difficulty level rather than numerical values obtained with manometry.
    • Staff can wear N95 and eye protection if there is concern regarding RMST as an aerosol-generating activity. Here at NYU, we call the look COVID chic.
    • When in doubt, always check in with your Infection Prevention and Control Department. Many pieces of equipment may be approved for single-patient use!

 

3. If you provide it to one patient, you must provide it to all: One size fits all does not fit everyone!

• • • There is no one size fits all in patient-centered care!
    • Outlining selection criteria, targeting specific patients, and obtaining baseline measurements for comparison to normative data can help focus efforts and resources.
    • Make it specific. Target a patient’s deficit, choose an appropriate goal, and get to work.
    • Success and time will allow for program scaling.
    • Initially, you may consider choosing patients who move along a care continuum within the same health system (acute care -> acute rehab -> home care). This can be an excellent way to track and demonstrate success.

 

4. No evidence supports the use of RMST in acute or acute rehab settings. Check again!

• The setting is not what needs to be proven effective, but rather that using RMST can be effective for working to improve patient sequelae.
• There is strong evidence to support the use of EMST in patients with Parkinson’s disease, stroke, multiple sclerosis, and those undergoing pulmonary rehabilitation. In addition, emerging evidence with additional populations (head and neck cancer, athletes, etc.).
• These are populations frequently encountered in our acute and acute rehabilitation settings. Don’t believe us? Well, allow us to prove it to you!
• Patients with severe lung disease awaiting transplantation who participated in Inspiratory Muscle Strength Training in addition to pulmonary rehab demonstrated increased walking distance, ratio of carbon monoxide diffusion, and maximum inspiratory pressure (MIP) compared to those only participating in pulmonary rehabilitation (Pehlivian, 2018).
• EMST effectively stimulated hyoid elevation by targeting the suprahyoid muscle group in patients with dysphagia status post-stroke, which reduced pharyngeal airway invasion (Park, Change & Kim, 2016).
• Use of RMST in patients with head and neck cancer patients who chronically aspirated resulted in increased maximum expiratory pressure (MEP), which is the force needed for strong coughs to expel aspirated material (Hutcheson et al., 2018).
• Respiratory Muscle Training improved muscle strength, fatigue, and dysarthria in stroke patients with respiratory muscle strength weakness (Liaw et al. Medicine, 2020).

 

5. It’s too hard to continue the program after leaving a current level of care. But is it WORTH it?

• Transitioning to a new environment with new people can be incredibly overwhelming!
• It is hard enough for patients to hold on to their hearing aids, dentures, and glasses during the move, let alone RMST devices! How can we ensure the transfer of goals?
• Here is the key: partnership, partnership, and, did we say, partnership?
• It is a bit of extra effort, but this can go a long way to facilitate an evidence-based program! Whom can we work with to ensure program transition? Other SLPs within our own facility or within a different facility. We share common goals, so why not unite.
• We can also work with family and/or friends for training on use of RMST. In reality, these are often the people who spend the most time with our patients. We want them to feel comfortable with the program application to facilitate carry-over.
• Things to communicate: current device threshold (cmH20) and level of cueing.
• Now, ensuring safe transfer of equipment is a separate battle.
• Let us start with reality. Accidents happen and things do get lost. Work with your manager to have extra room in the budget to account for loss and damage.
• Consider using a facility and patient-labeled bag to keep all materials together.
• In an ideal world, we would always know when a patient is discharging, and we would be there to ensure the device goes with them. However, let’s be honest: discharge dates are fluid and BUSY! We cannot always directly supervise the process (as much as our Type A personalities would love that). We make “to go” kits, try to reach out to nursing, patient care technicians, family, etcetera, to ensure that belongings are packed and ready to go.

 

6. Hospitals will not support the cost of RMST equipment: Money talks but so does EBP!  

• Choose your best articles (see point 4) and match them with the best advocates for your target population (and persevere even if they say no at first- Rome was not built in a day!)
• Start small.

7. Choosing the right target population for a pilot can be the recipe for success and building momentum. You have to start somewhere!

• Manometry is an extra expense, BUT you are paying it forward. This allows us to identify the patients who need the program rather than distributing devices like Oprah on her Christmas special. You get an EMST! YOU get an EMST! and  YOU get an EMST!
• Consider checking stimulability for RMST with common hospital devices that are readily available (Incentive spirometer). This is NOT a replacement for RMST.
• EMST devices can be calibrated through device trials ( the low tech method) if manometry cost is a concern.
• Motivated patients may purchase their own devices for use.

 

8. It is too complex for our patients to carry- over after therapy: You do not know unless you try!

• While this concern is valid, there are techniques that can be utilized to facilitate improved use and carryover of RMST devices. Here’s a few to try on for size:
• Involving family and the interdisciplinary team, using visual aids, and suggesting correlating device use to daily activities (e.g., like you are blowing on hot coffee) have translated to more functional and reliable patient use.
• Practice makes perfect! Start by providing consistent support and exposure and wean level of cueing over time. Good habits do not develop overnight!

 

9. There is not a strong relationship between respiratory insufficiency and swallowing: Cough Cough: Let me clear my throat 

• Brace yourself for the misconception we’ve encountered countless times: Why should speech-language pathologists target respiratory muscles in therapy? What does this have to do with speech or swallowing?
• Past and current research supports the relationship between respiratory insufficiency and diminished cough in increasing the risk of dysphagia and the susceptibility to complications, including aspiration pneumonia.
• Patients with respiratory insufficiency may have difficulty coordinating the apneic swallowing period with a swallow trigger, diminishing the timing of their airway closure.
• Some literature demonstrates that the incidence of pneumonia is increased with silent aspiration, which supports the importance of an intact cough reflex.
• Studies are additionally targeting the role of cough reflex testing and its role in reducing pneumonia in acute stroke patients (Miles et al., 2013).
• The principles guiding RMST for cough have been adapted from well-established evidence related to limb strength training.

 

10. You can’t monitor for progress: Show me the numbers.

• Of course, you can! It is not always easy for our patients to feel their progress, so we try to show progress objectively so that it feels tangible.
• Objective values are also helpful when speaking to teams about the trajectory of patient improvement. So, let us get to it- how can we measure progress with RMST?
• One way to do so is repeating manometry to measure increasing MIP/MEP, then comparing those numbers to initial evaluation.
• Another way is to increase the device threshold and placing values on tracking sheets. This allows us to demonstrate weekly progress with program progression.
• A final way is to repeat swallow studies. Here, we utilize the Penetration Aspiration (PAS) scale to grade the severity of airway invasion as observed on instrumental assessments. We can review this scale with patients to demonstrate functional improvement.

 

11. The medical team will not approve a new protocol: Old habits die-hard!  

• First, no medical team orders are needed for the general population!
• Find your champion (You cannot please everyone, but do you really need to? NOPE. Some would say it is about quality, not quantity).
• Find a guinea pig (also called an advocate) to try the device so they know it’s not so bad.
• Use Inspiratory Muscle Training and its strong history as a basis for understanding rationale/bringing people on board.

About the Authors:

Jessica Goldstein, MA, CCC-SLP is a medical speech- language pathologist with 4 years of clinical experience. She is currently a staff therapist working within both acute care and inpatient rehabilitation units at NYU Langone hospital. Special interests include dysphagia management in heart and lung transplant, tracheostomy management, and critical care.  

 

Christina Moriarty, MS-CCC-SLP is a senior speech language pathology at NYU Langone with 12 years of clinical experience. Her work focuses on speech/swallow assessment on patients in the ICU setting including those with transplants and head and neck cancer. She has a special interest in assessment and treatment methods in medically complex Patients including those with lung or multi-organ transplants.

 

Keri Danziger, MA CCC-SLP is a medical speech pathologist with over 20 years of clinical experiences. She is currently, the supervisor of adult, inpatient acute care and acute rehabilitation services at NYU Langone Health main campus. Her interests include critical care, patients status post-transplant, head and neck cancer and difficult airways.

 

References

Chiara, T., Martin, A. D., Davenport, P. W., & Bolser, D. C. (2006). Expiratory muscle strength training in persons with multiple sclerosis having mild to moderate disability: effect on maximal expiratory pressure, pulmonary function, and maximal voluntary cough. Archives of physical medicine and rehabilitation, 87(4), 468–473. https://doi.org/10.1016/j.apmr.2005.12.035

Garber, C. E., Blissmer, B., Deschenes, M. R., Franklin, B. A., Lamonte, M. J., Lee, I. M., Nieman, D. C., Swain, D. P., & American College of Sports Medicine (2011). American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Medicine and science in sports and exercise, 43(7), 1334–1359. https://doi.org/10.1249/MSS.0b013e318213fefb

Hegland, K. W., Davenport, P. W., Brandimore, A. E., Singletary, F. F., & Troche, M. S. (2016). Rehabilitation of Swallowing and Cough Functions Following Stroke: An Expiratory Muscle Strength Training Trial. Archives of physical medicine and rehabilitation, 97(8), 1345–1351. https://doi.org/10.1016/j.apmr.2016.03.027

Hoffman, M., Chaves, G., Ribeiro-Samora, G. A., Britto, R. R., & Parreira, V. F. (2017). Effects of pulmonary rehabilitation in lung transplant candidates: a systematic review. BMJ open, 7(2), e013445. https://doi.org/10.1136/bmjopen-2016-013445

Hutcheson, K. A., Barrow, M. P., Plowman, E. K., Lai, S. Y., Fuller, C. D., Barringer, D. A., Eapen, G., Wang, Y., Hubbard, R., Jimenez, S. K., Little, L. G., & Lewin, J. S. (2018). Expiratory muscle strength training for radiation-associated aspiration after head and neck cancer: A case series. The Laryngoscope, 128(5), 1044–1051. https://doi.org/10.1002/lary.26845

Laciuga, H., Rosenbek, J. C., Davenport, P. W., & Sapienza, C. M. (2014). Functional outcomes associated with expiratory muscle strength training: narrative review. Journal of rehabilitation research and development, 51(4), 535–546. https://doi.org/10.1682/JRRD.2013.03.0076

Liaw, M. Y., Hsu, C. H., Leong, C. P., Liao, C. Y., Wang, L. Y., Lu, C. H., & Lin, M. C. (2020).Respiratory muscle training in stroke patients with respiratory muscle weakness, dysphagia, and dysarthria – a prospective randomized trial. Medicine, 99(10), e19337. https://doi.org/10.1097/MD.0000000000019337

Miles, A., Zeng, I. S., McLauchlan, H., & Huckabee, M. L. (2013). Cough reflex testing in Dysphagia following stroke: a randomized controlled trial. Journal of clinical medicine research, 5(3), 222–233. https://doi.org/10.4021/jocmr1340w

Park, J. S., Oh, D. H., Chang, M. Y., & Kim, K. M. (2016). Effects of expiratory muscle strength training on oropharyngeal dysphagia in subacute stroke patients: a randomized controlled trial. Journal of oral rehabilitation, 43(5), 364–372. https://doi.org/10.1111/joor.12382

Pehlivan, E., Mutluay, F., Balcı, A., & Kılıç, L. (2018). The effects of inspiratory muscle training on exercise capacity, dyspnea and respiratory functions in lung transplantation candidates: a randomized controlled trial. Clinical rehabilitation, 32(10), 1328–1339. https://doi.org/10.1177/0269215518777560

Pitts, T., Bolser, D., Rosenbek, J., Troche, M., Okun, M. S., & Sapienza, C. (2009). Impact of expiratory muscle strength training on voluntary cough and swallow function in Parkinson disease. Chest, 135(5), 1301–1308. https://doi.org/10.1378/chest.08-1389

Rosenbek, J. C., Robbins, J. A., Roecker, E. B., Coyle, J. L., & Wood, J. L. (1996). A penetration-aspiration scale. Dysphagia, 11(2), 93–98. https://doi.org/10.1007/BF00417897