Authors:
C. Bianchi
M. Grandi
G. Felisari
Affiliations:
From the Divisione di Riabilitazione,
Fondazione Istituto Sacra Famiglia,
Cesano Boscone (Milano), Italy (CB,
GF); and the Dipartimento Medicina
Riabilitativa, Ospedale Valduce,
Como, Italy (MG).
Correspondence:
All correspondence and requests for
reprints should be addressed to Carlo
Bianchi, Divisione di Riabilitazione,
Fondazione Istituto Sacra Famiglia,
P.zza Mons. Moneta, 1—20090
Cesano Boscone (Milano), Italy.
0894-9115/04/8303-0216/0
American Journal of Physical
Medicine & Rehabilitation
Copyright © 2004 by Lippincott
Williams & Wilkins
DOI: 10.1097/01.PHM.0000113408.96258.06
216
Pulmonary
Case Report
Efficacy of Glossopharyngeal
Breathing for a Ventilator-
Dependent, High-Level Tetraplegic
Patient After Cervical Cord Tumor
Resection and Tracheotomy
ABSTRACT
Bianchi C, Grandi M, Felisari G: Efficacy of glossopharyngeal breath-
ing for a ventilator-dependent, high-level tetraplegic patient after cervi-
cal cord tumor resection and tracheotomy. Am J Phys Med Rehabil
2004;83:216 –219.
This case study was undertaken to describe the use and limitations of
glossopharyngeal breathing (GPB) by a ventilator-dependent, trache-
otomized patient after cervical tumor resection. A 6-yr, 8-mo– old, tra-
cheotomized, ventilator-dependent boy, after cervical tumor resection,
learned GPB on his own and used it for ventilator-free breathing. Over
the next 16 yrs, his GPB efficacy improved to the point that, with a vital
capacity of 670 ml, his GPB maximum single-breath capacity increased
to 3300 ml. This was limited by the fact that at 2.9 l of lung volume, air
began to leak around the tracheostomy tube walls and out of the stoma.
Still, GPB permitted up to 12 hrs/day of ventilator-free breathing. Mea-
surements of assisted peak cough flow and GPB lung insufflations
exceeding vital capacity are the main measures that demonstrate ade-
quate tube fit to permit effective GPB in the presence of an indwelling
tracheostomy tube.
Key Words: Spinal Cord, Respiratory Paralysis, Tracheotomy, Reha-
bilitation, Glossopharyngeal Breathing
G lossopharyngeal breathing (GPB) involves the elevation and pump-like action
of the glottis to enter boluses (gulps) of air into the lungs, where they can be
stacked to increase lung volumes. A total of 100 postpolio patients were described
Am. J. Phys. Med. Rehabil. ● Vol. 83, No. 3
 TABLE 1
Data showing the changes over time of vital capacity (VC) and glossopharyngeal maximum
single-breath capacity (GPmaxSBC) and the percentage of predicted normal VC
Age, yrs 10
Absolute % Absolute
VC, liters 0.40 20
GPmaxSBC, liters 0.70 36
using it in 1955. They had GPB maxi-
mum single-breath capacities (GP-
maxSBC) that were five times greater
than their vital capacity (VC).1 Zum-
walt et al.2 confirmed GPB utility in
200 additional patients in 1956. Fiegel-
son et al.3 reported that peak cough
flows were significantly higher from
GPB maximal lung insufflations than
from maximal inspiration not assisted
by GPB. The importance of GPB as an
aid to coughing was further reported
by Collier et al.,4 Kelleher and Parida,5
and Mazza et al.6 Collier et al.4 reported
that GPB-aided cough compared favor-
ably with flows achieved by using me-
chanical insufflation-exsufflation.
Kelleher and Parida,5 Mazza et al.,6 and
Bach et al.7 also reported the use of
GPB as an alternative to ventilator use
and for chest wall and lung mobiliza-
tion. Bach et al.7 noted that patients
with no measurable VC can have GP-
maxSBCs exceeding 3 liters and be free
of ventilatory assistance when awake.
Several articles investigated the
use of GPB by tetraplegic patients
with cervical spinal cord lesions. Met-
calf8 reported GPB increases in lung
expansion from VCs of 59% to GP-
maxSBCs of 81% on average for 23
such patients, and Montero et al.9
similarly reported increases from VCs
of 65% to GPmaxSBCs of 95% of pre-
dicted normal for 14 others. Bach and
Alba10 and Bach11 described six high-
level, ventilator-dependent cervical
cord–injured patients who mastered
GPB after decannulation, tracheos-
tomy closure, and switching to non-
invasive ventilatory support, thus
showing the benefit of combining
GPB use with noninvasive positive-
March 2004
11 12 13
% Absolute % Absolute
0.50 24 0.64 26 0.67
1.04 50 1.32 53 1.47
pressure ventilatory support. The
mean GPmaxSBC of the group was
2205 ml, despite a mean VC of 402
ml.
Although described for noninva-
sive ventilator users, postpoliomyeli-
tis, or high-level cervical spine in-
jury, GPB has not been reported in
other pathologic conditions of the
cervical spine. It is also not obvious
that GPB can be effective in the pres-
ence of tracheostomy tubes because
lung insufflation beyond one’s VC
creates lung recoil pressures that
cause the air to leak out of the stoma
around the outer walls of capped
tubes. GPB is also always ineffective
during ventilatory support via trache-
ostomy. We report a patient who,
from age 7, after cervical cord tumor
resection, used GPB as the only
means of autonomous breathing. We
also discuss efficacy limitations
caused by tracheostomy.12
CASE REPORT
A 22-yr-old man had a history of
rapidly progressive tetraparesis at 15
mos of age because of a C3-T1 in-
tramedullary subependymoma. He
underwent tumor resections at that
time and at 4 yrs 10 mos of age. This
left him with C3 complete sensory-
motor tetraplegia and ventilator de-
pendence. Radioscopic examination
revealed right diaphragm paralysis
and minimal left diaphragm move-
ment. He was discharged home at 61⁄2
yrs of age using ventilatory support
via an unfenestrated tracheostomy
tube without a cuff.
He learned GPB on his own at
Glossopharyngeal Breathing
20 22
% Absolute % Absolute %
27 0.67 15 0.67 15
60 2.84 64 3.34 75
age 7 and began using it for autono-
mous breathing for almost 2 hrs/day,
despite having no ventilator-free
breathing ability otherwise. The use
of GPB facilitated schooling by elim-
inating the noise of mechanical ven-
tilation. By 8 yrs 6 mos of age, he was
only using his ventilator for 5 hrs
during daytime hours, relying on
GPB the rest of the day. At this point,
GPB training included monitoring
the volume of air per gulp, gulps per
breath, GPB tidal volumes, and GP-
maxSBC. Within a few weeks, the GP-
maxSBC increased by 1040 ml (Table
1), despite using thoracolumbar
bracing and having a S scoliotic
curve of 87 degrees, from T11 to L5,
on the left and 100 degrees, from C7
to T11, on the right.13
On electrodiagnostic testing,
right diaphragm motor action poten-
tial latency was 4.3 msecs, amplitude
was 80 ␮V, left diaphragm motor ac-
tion potential latency was 4.6 msecs,
and amplitude was 200 ␮V. Both
phrenic nerve conduction velocities
were normal. Thus, reduced motor
action potentials were documented.
Currently, his VC is 0.67 liters,
but his GPmaxSBC is 3.34 liters with
his tube capped. Maximum insuffla-
tion GPB also increased peak cough
flow from 20 liters/min to 250 liters/
min, and 330 liters/min with a con-
comitant abdominal thrust (Access
peak flowmeter, Health-Scan, Cedar
Grove, NJ). During GPB air began to
leak around the tube and out of the
stoma at 2.90 liters of lung insuffla-
tion. He continues to have no venti-
lator-free breathing ability without
using GPB, but he has 12 hrs with it.
217
During daytime ventilator use, trans-
cutaneous oxygen was 96.5 mm Hg
and transcutaneous carbon dioxide
was 30 mm Hg. When using GPB,
transcutaneous oxygen was 95.2 mm
Hg and transcutaneous carbon diox-
ide was 35.5 mm Hg. Although he
had multiple hospitalizations and
pneumonias before age 7, he has had
none since then.
DISCUSSION
GPB can provide ventilator-free
breathing, mobilize lung tissues and
chest walls, improve cough, increase
ventilator-free breathing,14 and elim-
inate fear of sudden ventilator failure.
This case also demonstrated its po-
tential use by ventilator users with
tracheostomy tubes and the fact that,
even with a relatively tight fit, leaking
around the tube can occur, limiting
the ability to fully insufflate the lungs
by GPB. Although many bulbar polio-
myelitis patients underwent trache-
ostomies to manage airway secre-
tions while using iron lungs for
ventilatory support, loose tube fit and
severe bulbar dysfunction would have
hampered their ability to use GPB.
Although not apparently reported, it
is likely that some such patients did
learn and use the technique to some
degree.
Dail et al.1 stated that relatively
few children learned GPB and that
the youngest to learn it, learned it on
his own at 4 yrs of age.15 This case,
however, demonstrated a child with
spinal cord tumors, severe scoliosis,
ventilatory failure, and a tracheos-
tomy tube who benefited from
GPB.16 –18 It is also the first longitu-
dinal study of GPB use for a 16-yr
period.
When the tracheostomy tube fit
is tight and gulped or insufflated air
does not readily leak out of the stoma
around the tube with a deflated cuff,
GPB can be tried. It can also be effec-
tive for patients with tight-fitting fe-
nestrated uncuffed tubes that can be
capped during GPB. This patient,
218 Bianchi et al.
with excellent bulbar muscle func-
tion, assisted peak cough flow, and
ability to air stack, is an excellent
candidate for decannulation and
transition to noninvasive methods of
ventilatory assistance, and he is con-
sidering this option. It has been re-
ported that about two-thirds of high-
level spinal cord injury patients who
were transferred from tracheostomy
to noninvasive ventilation and had
their ostomy sites closed were able to
use GPB for ventilator-free breath-
ing.10 Unless opting for decannula-
tion, the patient will continue to fear
accidental ventilator disconnection
or failure because of ineffectiveness
of GPB during tracheostomy ventila-
tion. Several centers that decannu-
late ventilator-dependent patients
and switch them to noninvasive ven-
tilation cite GPB as a key reason for
doing this.12,19
Our patient took 40 – 47 gulps to
achieve lung insufflations of 2.84 –
3.34 liters. Although functional tidal
breaths usually require three to eight
gulps and maximal GPB volumes ne-
cessitate many more gulps,7 it is
likely that this patient’s gulp effi-
ciency was poor because of leak
around the tube.
Interestingly, GPB has been re-
ported to be used by deep sea divers
to achieve lung volumes greater than
VC to permit longer periods of sub-
mersion.5 In one instance, a post-
polio patient had learned GPB in
childhood many years before acute
poliomyelitis for longer submersion
when diving.1 This technique contin-
ues to be used today by many divers,
including record holders of apnea
submersion. These facts further im-
ply that GPB might well be taught to
patients with good bulbar muscle
function whose VCs have not dimin-
ished to the point of necessitating
ventilatory assistance.
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Continuing Call for Papers

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March 2004 Glossopharyngeal Breathing 219