Expiratory Muscle Strength Training in patients After Total Laryngectomy; A Feasibility Pilot Study

Abstract

Objectives: Expiratory muscle strength training (EMST) is a threshold based device-driven treatment for improving expiratory pressure. EMST proved to be effective in different patient groups to improve cough function. To date, EMST has not been tested in the total laryngectomy population (TL). Methods: This prospective, randomized case-series study examined feasibility, safety, and compliance of EMST in a group of TL participants and its effects on pulmonary function, physical exertion, fatigue, and vocal functioning. Ten TL participants were included in the study to perform a 4 till 8 weeks of EMST. Objective and subjective outcome measures included manometry, spirometry, cardio pulmonary exercise testing (CPET), voice recordings, and patient reported outcome measures. Group means were reported and estimates of the effect are shown with a 95% confidence interval, using single sample t-tests. Results: Nine participants completed the full study protocol. Compliance to the training program was high. All were able to perform the training, although it requires adjustments of the device and skills of the participants. Maximum expiratory pressure (MEP) and vocal functioning in loudness improved over time. After EMST no changes were seen in other objective and subjective outcomes. Conclusions: EMST appears to be feasible and safe after total laryngectomy. MEP improved over time but no improvement in the clinically relevant outcome measures were seen in this sample of relatively fit participants. Further investigation of the training in a larger group of participants who report specifically pulmonary complaints is recommended to investigate if the increase in MEP results in clinical benefits. Level of Evidence: 4

Hypotussic cough in persons with dysphagia: biobehavioral interventions and pathways to clinical implementation

“…Pilot investigations on EMST in multiple systems atrophy ( 89 ) have found direct improvements in MEPs, yet did not find statistically significant changes in PEFR. Similar limitations and/or findings have been observed in head and neck cancer patients ( 83 , 87 , 88 ).…”

“…In six participants who underwent supracricoid partial laryngectomy for laryngeal cancer a mean increase in PEFR from 371.67 to 451.33 L/min or 21% was observed after 4-weeks of EMST ( 87 ). In contrast, in a small group of total laryngectomy participants ( n = 10), PEFR did not improve after 4 and 8 weeks of EMST as compared to baseline ( 88 ). This may be due, in part, to altered physiologic anatomy and the inability to generate subglottic air pressure due to removal of the larynx—leaving these individuals dependent only on volume and speed of expiratory airflow to improve airway clearance ( 88 ).…”

“…In contrast, in a small group of total laryngectomy participants ( n = 10), PEFR did not improve after 4 and 8 weeks of EMST as compared to baseline ( 88 ). This may be due, in part, to altered physiologic anatomy and the inability to generate subglottic air pressure due to removal of the larynx—leaving these individuals dependent only on volume and speed of expiratory airflow to improve airway clearance ( 88 ). Despite these findings and limitations, these studies are essential as they highlight the need for larger, adequately powered investigations in these patient populations.…”

“…Typically, EMST regimens involve breathing through the device for 25 repetitions (five sets of five repetitions) five days per week for four to five weeks ( 35 , 62 , 70 , 72 , 75 , 78 , 81 ). Although EMST has consistently been shown to improve MEPs, there is a rising number of investigations which demonstrate its efficacy to improve measures of voluntary and reflex cough ( 70 , 71 , 74 , 82 – 88 ).…”

Maximal cardiopulmonary exercise testing in laryngectomised patients using different heat and moisture exchangers – feasibility and exercise responses

“…Previously, exercise testing using a custom-made adapter attached to the base plate of the heat and moisture exchanger, but without the heat and moisture exchanger being in place, proved to be feasible. 20 , 21 However, this approach discards the effect of the heat and moisture exchanger on upper airway physiology. In addition, it creates an unnatural situation for patients, which may affect the results of exercise testing.…”