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Swallowing with Noninvasive Positive-Pressure Ventilation (NPPV) in Individuals with Muscular Dystrophy: A Qualitative Analysis


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 [33]) and took part in semi-structured interviews. The interviews were audio recorded, transcribed, and verified. Phenomenological qualitative research methods were used to code ( 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.

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  1. 1.

    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.

    PubMed  Google Scholar 

  2. 2.

    Khirani S, Ramirez A, Aubertin G, et al. Respiratory muscle decline in Duchenne muscular dystrophy. Pediatr Pulmonol. 2014;49(5):473–81.

    PubMed  Google Scholar 

  3. 3.

    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.

    PubMed  Google Scholar 

  4. 4.

    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.

    PubMed  Google Scholar 

  5. 5.

    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.

    CAS  PubMed  Google Scholar 

  6. 6.

    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.

    PubMed  Google Scholar 

  7. 7.

    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.

    PubMed  Google Scholar 

  8. 8.

    Gross RD. Subglottic air pressure and swallowing. Perspect Swallowing Swallowing Disord (Dysphagia). 2009;18:13–8.

    Google Scholar 

  9. 9.

    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.

    Google Scholar 

  10. 10.

    Siebens AA, Tippett DC, Kirby N, French J. Dysphagia and expiratory air flow. Dysphagia. 1993;8(3):266–9.

    CAS  PubMed  Google Scholar 

  11. 11.

    Nash M. Swallowing problems in the tracheotomized patient. Otolaryngol Clin North Am. 1988;21(4):701–9.

    CAS  PubMed  Google Scholar 

  12. 12.

    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.

    CAS  PubMed  Google Scholar 

  13. 13.

    Davis LA, Thompson Stanton S. Characteristics of dysphagia in elderly patients requiring mechanical ventilation. Dysphagia. 2004;19(1):7–14.

    PubMed  Google Scholar 

  14. 14.

    Durbin CG Jr. Tracheostomy: why, when, and how? Respir Care. 2010;55(8):1056–68.

    PubMed  Google Scholar 

  15. 15.

    Griese M, Felber J, Reiter K, et al. Airway inflammation in children with tracheostomy. Pediatr Pulmonol. 2004;37(4):356–61.

    CAS  PubMed  Google Scholar 

  16. 16.

    Bach JR, Martinez D. Duchenne muscular dystrophy: continuous noninvasive ventilatory support prolongs survival. Respir Care. 2011;56(6):744–50.

    PubMed  Google Scholar 

  17. 17.

    Hess DR. Noninvasive Ventilation for Neuromuscular Disease. Clin Chest Med. 2018;39(2):437–47.

    PubMed  Google Scholar 

  18. 18.

    Benditt JO. Full-time noninvasive ventilation: possible and desirable. Respir Care. 2006;51(9):1005–12 discussion 1012-1005.

    PubMed  Google Scholar 

  19. 19.

    Benditt JO, Boitano L. Respiratory treatment of amyotrophic lateral sclerosis. Phys Med Rehabil Clin N Am. 2008;19(3):559–72.

    PubMed  Google Scholar 

  20. 20.

    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.

    PubMed  Google Scholar 

  21. 21.

    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.

    PubMed  Google Scholar 

  22. 22.

    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.

    PubMed  Google Scholar 

  23. 23.

    Pierson DJ. History and epidemiology of noninvasive ventilation in the acute-care setting. Respir Care. 2009;54(1):40–52.

    PubMed  Google Scholar 

  24. 24.

    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.

    CAS  PubMed  Google Scholar 

  25. 25.

    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.

    PubMed  PubMed Central  Google Scholar 

  26. 26.

    Ishikawa Y, Miura T, Ishikawa Y, et al. Duchenne muscular dystrophy: survival by cardio-respiratory interventions. Neuromuscul Disord. 2011;21(1):47–51.

    PubMed  Google Scholar 

  27. 27.

    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.

    PubMed  PubMed Central  Google Scholar 

  28. 28.

    Sheehan DW, Birnkrant DJ, Benditt JO, et al. Respiratory management of the patient with Duchenne muscular dystrophy. Pediatrics. 2018;142(Suppl 2):S62–71.

    PubMed  Google Scholar 

  29. 29.

    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.

    PubMed  Google Scholar 

  30. 30.

    Tips for using your CPAP/BIPAP. 2018. Accessed 28 April 28, 2018.

  31. 31.

    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.

    PubMed  PubMed Central  Google Scholar 

  32. 32.

    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.

    PubMed  PubMed Central  Google Scholar 

  33. 33.

    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.

    PubMed  Google Scholar 

  34. 34.

    Benner P, editor. Interpretive phenomenology. Thousands Oak: Sage Publications; 1994.

    Google Scholar 

  35. 35.

    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.

    Google Scholar 

  36. 36.

    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.

    PubMed  PubMed Central  Google Scholar 

  37. 37.

    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.

    PubMed  PubMed Central  Google Scholar 

  38. 38.

    Bach JR. Mechanical insufflation-exsufflation. Comparison of peak expiratory flows with manually assisted and unassisted coughing techniques. Chest. 1993;104(5):1553–62.

    CAS  PubMed  Google Scholar 

  39. 39.

    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.

    PubMed  Google Scholar 

  40. 40.

    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.

    PubMed  Google Scholar 

  41. 41.

    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.

    Article  Google Scholar 

  42. 42.

    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.

    CAS  PubMed  Google Scholar 

  43. 43.

    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.

    PubMed  Google Scholar 

  44. 44.

    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.

    PubMed  PubMed Central  Google Scholar 

  45. 45.

    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.

    PubMed  Google Scholar 

  46. 46.

    Hadjikoutis S, Pickersgill TP, Dawson K, Wiles CM. Abnormal patterns of breathing during swallowing in neurological disorders. Brain. 2000;123(Pt 9):1863–73.

    PubMed  Google Scholar 

  47. 47.

    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.

    PubMed  Google Scholar 

  48. 48.

    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.

    PubMed  Google Scholar 

  49. 49.

    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.

    PubMed  Google Scholar 

  50. 50.

    Jenkins HM, Stocki A, Kriellaars D, Pasterkamp H. Breath stacking in children with neuromuscular disorders. Pediatr Pulmonol. 2014;49(6):544–53.

    CAS  PubMed  Google Scholar 

  51. 51.

    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.

    PubMed  Google Scholar 

  52. 52.

    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.

    PubMed  Google Scholar 

  53. 53.

    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.

    PubMed  Google Scholar 

  54. 54.

    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.

    PubMed  PubMed Central  Google Scholar 

  55. 55.

    Happel KI, Bagby GJ, Nelson S. Host defense and bacterial pneumonia. Semin Respir Crit Care Med. 2004;25(1):43–52.

    PubMed  Google Scholar 

  56. 56.

    Boitano LJ. Management of airway clearance in neuromuscular disease. Respir Care. 2006;51(8):913–24.

    PubMed  Google Scholar 

  57. 57.

    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.

    CAS  PubMed  Google Scholar 

  58. 58.

    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.

    PubMed  Google Scholar 

  59. 59.

    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.

    CAS  PubMed  Google Scholar 

  60. 60.

    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.

    CAS  PubMed  Google Scholar 

  61. 61.

    Addington WR, Stephens RE, Widdicombe JG, Rekab K. Effect of stroke location on the laryngeal cough reflex and pneumonia risk. Cough. 2005;1:4.

    PubMed  PubMed Central  Google Scholar 

  62. 62.

    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.

    PubMed  PubMed Central  Google Scholar 

  63. 63.

    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.

    CAS  PubMed  Google Scholar 

  64. 64.

    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.

    PubMed  Google Scholar 

  65. 65.

    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.

    PubMed  Google Scholar 

  66. 66.

    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.

    PubMed  Google Scholar 

  67. 67.

    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.

    PubMed  Google Scholar 

  68. 68.

    Bach JR, Ishikawa Y, Kim H. Prevention of pulmonary morbidity for patients with Duchenne muscular dystrophy. Chest. 1997;112(4):1024–8.

    CAS  PubMed  Google Scholar 

  69. 69.

    Evans JA, Whitelaw WA. The assessment of maximal respiratory mouth pressures in adults. Respir Care. 2009;54(10):1348–59.

    PubMed  Google Scholar 

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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.

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Correspondence to Deanna Britton.

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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).

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  • Noninvasive positive-pressure ventilation (NPPV)
  • Mouthpiece NPPV (M-NPPV)
  • Bilevel positive airway pressure (BPAP/BiPAP)
  • Swallowing
  • Deglutition
  • Dysphagia
  • Deglutition disorders