The purpose of the study is to describe experiences of swallowing with two forms of noninvasive positive-pressure ventilation (NPPV): mouthpiece NPPV (M-NPPV) and nasal bilevel positive airway pressure (BPAP) in people with muscular dystrophy. Ten men (ages 22–42 years; M = 29.3; SD = 7.1) with muscular dystrophy (9 with Duchenne’s; 1 with Becker’s) completed the Eating Assessment Tool (EAT-10; Ann Otol Rhinol Laryngol 117(12):919-924 ) and took part in semi-structured interviews. The interviews were audio recorded, transcribed, and verified. Phenomenological qualitative research methods were used to code (Dedoose.com) and develop themes. All participants affirmed dysphagia symptoms via responses on the EAT-10 (M = 11.3; SD = 6.38; Range = 3–22) and reported eating and drinking with M-NPPV and, to a lesser extent, nasal BPAP. Analysis of interview data revealed three primary themes: (1) M-NPPV improves the eating/drinking experience: Most indicated that using M-NPPV reduced swallowing-related dyspnea. (2) NPPV affects breathing–swallowing coordination: Participants described challenges and compensations in coordinating swallowing with ventilator-delivered inspirations, and that the time needed to chew solid foods between ventilator breaths may lead to dyspnea and fatigue. (3) M-NPPV aids cough effectiveness: Participants described improved cough strength following large M-NPPV delivered inspirations (with or without breath stacking). Although breathing–swallowing coordination is challenging with NPPV, participants reported that eating and drinking is more comfortable than when not using it. Overall, eating and drinking with NPPV delivered via a mouthpiece is preferred and is likely safer for swallowing than with nasal BPAP. M-NPPV (but not nasal BPAP) is reported to improve cough effectiveness, an important pulmonary defense in this population.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
van den Engel-Hoek L, Erasmus CE, Hendriks JC, et al. Oral muscles are progressively affected in Duchenne muscular dystrophy: implications for dysphagia treatment. J Neurol. 2013;260(5):1295–303.
Khirani S, Ramirez A, Aubertin G, et al. Respiratory muscle decline in Duchenne muscular dystrophy. Pediatr Pulmonol. 2014;49(5):473–81.
Nozaki S, Umaki Y, Sugishita S, Tatara K, Adachi K, Shinno S. Videofluorographic assessment of swallowing function in patients with Duchenne muscular dystrophy. Rinsho Shinkeigaku. 2007;47(7):407–12.
Hanayama K, Liu M, Higuchi Y, et al. Dysphagia in patients with Duchenne muscular dystrophy evaluated with a questionnaire and videofluorography. Disabil Rehabil. 2008;30(7):517–22.
Aloysius A, Born P, Kinali M, Davis T, Pane M, Mercuri E. Swallowing difficulties in Duchenne muscular dystrophy: indications for feeding assessment and outcome of videofluroscopic swallow studies. Eur J Paediatr Neurol. 2008;12(3):239–45.
Hamanaka-Kondoh S, Kondoh J, Tamine K, et al. Tongue pressure during swallowing is decreased in patients with Duchenne muscular dystrophy. Neuromuscul Disord. 2014;24(6):474–81.
Terzi N, Prigent H, Lejaille M, et al. Impact of tracheostomy on swallowing performance in Duchenne muscular dystrophy. Neuromuscul Disord. 2010;20(8):493–8.
Gross RD. Subglottic air pressure and swallowing. Perspect Swallowing Swallowing Disord (Dysphagia). 2009;18:13–8.
Fernandez-Bussy S, Mahajan B, Folch E, Caviedes I, Guerrero J, Majid A. Tracheostomy tube placement: early and late complications. J Bronchol Interv Pulmonol. 2015;22(4):357–64.
Siebens AA, Tippett DC, Kirby N, French J. Dysphagia and expiratory air flow. Dysphagia. 1993;8(3):266–9.
Nash M. Swallowing problems in the tracheotomized patient. Otolaryngol Clin North Am. 1988;21(4):701–9.
Amathieu R, Sauvat S, Reynaud P, et al. Influence of the cuff pressure on the swallowing reflex in tracheostomized intensive care unit patients. Br J Anaesth. 2012;109(4):578–83.
Davis LA, Thompson Stanton S. Characteristics of dysphagia in elderly patients requiring mechanical ventilation. Dysphagia. 2004;19(1):7–14.
Durbin CG Jr. Tracheostomy: why, when, and how? Respir Care. 2010;55(8):1056–68.
Griese M, Felber J, Reiter K, et al. Airway inflammation in children with tracheostomy. Pediatr Pulmonol. 2004;37(4):356–61.
Bach JR, Martinez D. Duchenne muscular dystrophy: continuous noninvasive ventilatory support prolongs survival. Respir Care. 2011;56(6):744–50.
Hess DR. Noninvasive Ventilation for Neuromuscular Disease. Clin Chest Med. 2018;39(2):437–47.
Benditt JO. Full-time noninvasive ventilation: possible and desirable. Respir Care. 2006;51(9):1005–12 discussion 1012-1005.
Benditt JO, Boitano L. Respiratory treatment of amyotrophic lateral sclerosis. Phys Med Rehabil Clin N Am. 2008;19(3):559–72.
Britton D, Benditt JO, Hoit JD. Beyond tracheostomy: noninvasive ventilation and potential positive implications for speaking and swallowing. Semin Speech Lang. 2016;37(3):173–84.
Bach JR, Tran J, Durante S. Cost and physician effort analysis of invasive vs. noninvasive respiratory management of Duchenne muscular dystrophy. Am J Phys Med Rehabil. 2015;94(6):474–82.
Theerakittikul T, Ricaurte B, Aboussouan LS. Noninvasive positive pressure ventilation for stable outpatients: CPAP and beyond. Cleve Clin J Med. 2010;77(10):705–14.
Pierson DJ. History and epidemiology of noninvasive ventilation in the acute-care setting. Respir Care. 2009;54(1):40–52.
Carron M, Freo U, BaHammam AS, et al. Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials. Br J Anaesth. 2013;110(6):896–914.
Passamano L, Taglia A, Palladino A, et al. Improvement of survival in Duchenne Muscular Dystrophy: retrospective analysis of 835 patients. Acta Myologica. 2012;31(2):121–5.
Ishikawa Y, Miura T, Ishikawa Y, et al. Duchenne muscular dystrophy: survival by cardio-respiratory interventions. Neuromuscul Disord. 2011;21(1):47–51.
Buddhe S, Cripe L, Friedland-Little J, et al. Cardiac management of the patient with Duchenne muscular dystrophy. Pediatrics. 2018;142(Suppl 2):S72–81.
Sheehan DW, Birnkrant DJ, Benditt JO, et al. Respiratory management of the patient with Duchenne muscular dystrophy. Pediatrics. 2018;142(Suppl 2):S62–71.
Brumbaugh D, Watne L, Gottrand F, et al. Nutritional and gastrointestinal management of the patient with Duchenne muscular dystrophy. Pediatrics. 2018;142(Suppl 2):S53–61.
Tips for using your CPAP/BIPAP. 2018. http://respicairpc.com/cpap-and-bipap-tips/. Accessed 28 April 28, 2018.
Wollinsky KH, Kutter B, Geiger PM. Long-term ventilation of patients with Duchenne muscular dystrophy: experiences at the Neuromuscular Centre Ulm. Acta Myologica. 2012;31(3):170–8.
Miura T, Takami A, Makino M, Ishikawa A, Ishikawa Y. Rate of oral intake and effects of mechanical insufflation-exsufflation on pulmonary complications in patients with duchenne muscular dystrophy. J Phys Ther Sci. 2017;29(3):487–90.
Belafsky PC, Mouadeb DA, Rees CJ, et al. Validity and reliability of the Eating Assessment Tool (EAT-10). Ann Otol Rhinol Laryngol. 2008;117(12):919–24.
Benner P, editor. Interpretive phenomenology. Thousands Oak: Sage Publications; 1994.
Yorkston K, Klasner ER, Swanson KM. Communication in context: a qualitative study of the experiences of individuals with multiple sclerosis. Am J Speech-Lang Pathol. 2001;10(2):126–37.
Baylor CR, Yorkston KM, Eadie TL. The consequences of spasmodic dysphonia on communication-related quality of life: a qualitative study of the insider’s experiences. J Commun Disord. 2005;38:395–419.
Yorkston K, Baylor C, Britton D. Speech versus speaking: the experiences of people with Parkinson’s disease and implications for intervention. Am J Speech-Lang Pathol. 2017;26(2s):561–8.
Bach JR. Mechanical insufflation-exsufflation. Comparison of peak expiratory flows with manually assisted and unassisted coughing techniques. Chest. 1993;104(5):1553–62.
Hoit JD, Lansing RW, Dean K, Yarkosky M, Lederle A. Nature and evaluation of dyspnea in speaking and swallowing. Semin Speech Lang. 2011;32(1):5–20.
Lederle A, Hoit JD, Barkmeier-Kraemer J. Effects of sequential swallowing on drive to breathe in young, healthy adults. Dysphagia. 2012;27(2):221–7.
Cleary S, Misiaszek JE, Kalra S, Wheeler S, Johnston W. The effects of lung volume recruitment on coughing and pulmonary function in patients with ALS. Amyotroph Lateral Scler. 2012. https://doi.org/10.3109/17482968.2012.720262.
Lang IM, Dana N, Medda BK, Shaker R. Mechanisms of airway protection during retching, vomiting, and swallowing. Am J Physiol Gastrointest Liver Physiol. 2002;283(3):G529–36.
Terzi N, Normand H, Dumanowski E, et al. Noninvasive ventilation and breathing-swallowing interplay in chronic obstructive pulmonary disease*. Crit Care Med. 2014;42(3):565–73.
Garguilo M, Lejaille M, Vaugier I, et al. Noninvasive mechanical ventilation improves breathing-swallowing interaction of ventilator dependent neuromuscular patients: a prospective crossover study. PLoS ONE. 2016;11(3):e0148673.
Martin-Harris B, Brodsky MB, Michel Y, Ford CL, Walters B, Heffner J. Breathing and swallowing dynamics across the adult lifespan. Arch Otolaryngol Head Neck Surg. 2005;131(9):762–70.
Hadjikoutis S, Pickersgill TP, Dawson K, Wiles CM. Abnormal patterns of breathing during swallowing in neurological disorders. Brain. 2000;123(Pt 9):1863–73.
Gross RD, Atwood CW Jr, Ross SB, Eichhorn KA, Olszewski JW, Doyle PJ. The coordination of breathing and swallowing in Parkinson’s disease. Dysphagia. 2008;23(2):136–45.
Troche MS, Huebner I, Rosenbek JC, Okun MS, Sapienza CM. Respiratory-swallowing coordination and swallowing safety in patients with Parkinson’s disease. Dysphagia. 2011;26(3):218–24.
van den Engel-Hoek L, de Groot IJ, Sie LT, et al. Dystrophic changes in masticatory muscles related chewing problems and malocclusions in Duchenne muscular dystrophy. Neuromuscul Disord. 2016;26(6):354–60.
Jenkins HM, Stocki A, Kriellaars D, Pasterkamp H. Breath stacking in children with neuromuscular disorders. Pediatr Pulmonol. 2014;49(6):544–53.
McKim DA, Katz SL, Barrowman N, Ni A, LeBlanc C. Lung volume recruitment slows pulmonary function decline in Duchenne muscular dystrophy. Arch Phys Med Rehabil. 2012;93(7):1117–22.
Bach JR, Bianchi C, Vidigal-Lopes M, Turi S, Felisari G. Lung inflation by glossopharyngeal breathing and “air stacking” in Duchenne muscular dystrophy. Am J Phys Med Rehabil. 2007;86(4):295–300.
Chiou M, Bach JR, Jethani L, Gallagher MF. Active lung volume recruitment to preserve vital capacity in Duchenne muscular dystrophy. J Rehabil Med. 2017;49(1):49–53.
Jeong JH, Yoo WG. Effects of air stacking on pulmonary function and peak cough flow in patients with cervical spinal cord injury. J Phys Ther Sci. 2015;27(6):1951–2.
Happel KI, Bagby GJ, Nelson S. Host defense and bacterial pneumonia. Semin Respir Crit Care Med. 2004;25(1):43–52.
Boitano LJ. Management of airway clearance in neuromuscular disease. Respir Care. 2006;51(8):913–24.
Smith Hammond CA, Goldstein LB, Zajac DJ, Gray L, Davenport PW, Bolser DC. Assessment of aspiration risk in stroke patients with quantification of voluntary cough. Neurology. 2001;56(4):502–6.
Smith-Hammond C, Goldstein LB, Horner RD, et al. Predicting aspiration in patients with ischemic stroke: comparison of clinical signs and aerodynamic measures of voluntary cough. Chest. 2009;135(3):769–77.
Addington WR, Stephens RE, Gilliland K, Rodriguez M. Assessing the laryngeal cough reflex and the risk of developing pneumonia after stroke. Arch Phys Med Rehabil. 1999;80(2):150–4.
Addington WR, Stephens RE, Gilliland KA. Assessing the laryngeal cough reflex and the risk of developing pneumonia after stroke: an interhospital comparison. Stroke. 1999;30(6):1203–7.
Addington WR, Stephens RE, Widdicombe JG, Rekab K. Effect of stroke location on the laryngeal cough reflex and pneumonia risk. Cough. 2005;1:4.
Pitts T, Bolser D, Rosenbek J, Troche M, Sapienza C. Voluntary cough production and swallow dysfunction in Parkinson’s disease. Dysphagia. 2008;23(3):297–301.
Bach JR, Saporito LR. Criteria for extubation and tracheostomy tube removal for patients with ventilatory failure: a different approach to weaning. Chest. 1996;110(6):1566–71.
Suarez AA, Pessolano FA, Monteiro SG, et al. Peak flow and peak cough flow in the evaluation of expiratory muscle weakness and bulbar impairment in patients with neuromuscular disease. Am J Phys Med Rehabil. 2002;81(7):506–11.
Ishikawa Y, Bach JR, Komaroff E, Miura T, Jackson-Parekh R. Cough augmentation in Duchenne muscular dystrophy. Am J Phys Med Rehabil. 2008;87(9):726–30.
Ueda Y, Suwazono S, Maedo S, Higuchi I. Profile of cognitive function in adults with duchenne muscular dystrophy. Brain Dev. 2017;39(3):225–30.
Culver BH, Graham BL, Coates AL, et al. Recommendations for a standardized pulmonary function report. An Official American Thoracic Society Technical Statement. Am J Respir Crit Care Med. 2017;196(11):1463–72.
Bach JR, Ishikawa Y, Kim H. Prevention of pulmonary morbidity for patients with Duchenne muscular dystrophy. Chest. 1997;112(4):1024–8.
Evans JA, Whitelaw WA. The assessment of maximal respiratory mouth pressures in adults. Respir Care. 2009;54(10):1348–59.
The authors would like to acknowledge the assistance of Breanna Schwarz from the Speech Swallowing & Respiration (SSR) Lab at Portland State University and Elizabeth Pullen, Isabella Bareiss, Valerie Phan Brown, and Danielle Rincon from the Speech Acoustics and Physiology Lab at the University of Arizona.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Britton, D., Hoit, J.D., Benditt, J.O. et al. Swallowing with Noninvasive Positive-Pressure Ventilation (NPPV) in Individuals with Muscular Dystrophy: A Qualitative Analysis. Dysphagia 35, 32–41 (2020). https://doi.org/10.1007/s00455-019-09997-6
- Noninvasive positive-pressure ventilation (NPPV)
- Mouthpiece NPPV (M-NPPV)
- Bilevel positive airway pressure (BPAP/BiPAP)
- Deglutition disorders