Episode 49: Are You Down with RMT?

The goal is to learn , inspire and bring cardiopalm to the forefront of conversation . Thanks for joining me today and let's get after it . Hello , hello and welcome to Talking All Things Cardiopulm . I am your host , Dr . Rachele Burriesci .

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Today we're going to be doing some live demos on my YouTube channel and just to have a little bit of that video feedback if you have been on the fence , if you're not quite ready to book that demo or you just want more information . So I'm really excited about that . I'll be getting some of those videos up , probably this week .

So that was a little bit fun and different for today , and my plan for today was to talk about respiratory muscle training . So this is something that has been on my podcast list for a long time .

It's something that I'm actually really passionate about and while I was in academia it was going to be my academic research route and then the pandemic happened , so really kind of got stunted there but was able to do a case study and I should probably get that written up and publish because so much good data , just a huge proponent of RMT .

I think there's so much benefit . It's such an easy device or such an easy intervention to include and is something that the patient can do outside of your therapy session . So we're going to talk about it just in a little bit more detail and kind of break down some of the nitty-gritty Before I do that .

My plan was to potentially watch the on-demand version of this from CSM because I wasn't able to attend it live but I am having a hard time accessing on-demand for CSM . So hoping to get that figured out . But I did look through the handout and it's actually very much in line with what I was teaching my students , what I did in my case study .

So I figured at least give a brief understanding of what RMT is and how we might assess it and how we'll potentially utilize it in a session . And this is probably something I'm going to be diving into over the next few weeks because I just have that like I don't know . I'm at itch to kind of jump back into some of that research component .

So we'll see where that goes . I have so many ideas with RMT . Covid happened and I had a plan to do RMT with COVID patients and it just never worked out .

But RMT and long COVID , I think , is one of those populations that I would love to see data points looked at over time , because breathing exercises in and of itself have been so beneficial for my long COVID patients , but including this type of intervention can be super useful .

I actually had two of my long COVID patients do this , but they were virtual , so I didn't have a starting MIP and MEP to compare to , and I really wish I had a device that I could send if the person's not close enough for me to drive to , but I have so many . I have , like , some thoughts happening here , so we'll see how that goes .

So respiratory muscle training RMT is a lot of times in the research better known as IMT , inspiratory muscle training .

Rmt is kind of a combination of inspiratory and expiratory muscle training , and when I talk about this type of intervention , I like to talk about RMT , because if I'm treating this patient and I'm utilizing this as an intervention , I prefer to both assess and intervene with inhalation and exhalation , and I have lots of reasons for that .

But essentially we need to be able to have an objective number . How can we actually assess respiratory muscle strength ? And so a direct measurement of this is to utilize something called MIP and MEP .

Mip is maximal inspiratory pressure and MEP is maximal expiratory pressure and essentially you need a device that can measure this and there aren't that many , so I'm kind of pumping some kind of frame . I actually had a grant to get a RMT device and so I was utilizing the MicroRPM and it's an easy tool .

It's easy to change out the mouth pieces for your patients and it has basically a switch . So you switch it into MIP , you switch it into MIP . They also have typically a SNP option . I did not utilize SNIP . Snp is SNF nasal inspiratory pressure so essentially you're putting a probe in the nose and sniffing the MIP .

Mep is a mouth device so your lips go around a tube and then you're either maximally inhaling or maximally exhaling . But essentially it can give you data .

It gives you an objective number for respiratory muscle strength , which is super important if you're doing research and to also have like a really nice pre and post , even if you are just utilizing it as an intervention in your clinic . So lots of research has been happening in the RMT world . I was actually looking at RMT in heart failure for a bit .

I was looking at RMT in asthmatics for a bit and my new sort of like push is really that RMT in COVID and long COVID . I have no doubt that this is an intervention that can be utilized long-term and also have like a lot of different benefits .

So to kind of go through some of the nuance between MIP and MEP , there are some normative data on what that looks like and I actually compared one of my articles with one of the newer CSM articles and it's the same chart . So my initial reference value is from 2014, . So we're just within that 10-year window .

It's from Schlauser et al and it was a systematic review looking at reference values for maximal inspiratory pressure . So MIP , not MEP , and it broke it down into age group . So from 18 to 29 was one age group . It was about like a nine-year gap on each one 30 to 39 , 40 to 49 , 50 to 59 , so on and so forth .

And then it broke down the mean MIP for men and women and it broke it into two categories and each category has a mean as well as a range , so you can see the low end of the range and the high end of the range , which I think is really important . I have to look back at my I don't know my MIP value off the top of my head .

I should have pulled that out before I started , but I feel like I was on the lower end of my age category , if I remember correctly , and there is also predictive equations . So what I have for my predictive equations is different than what the CSM presentation held .

The predictive equation that I have was broken up into both MIP and MEP , genders and age groups , so age group from 20 to 54 , another age group from 55 to 80 , and then greater than 65 . And essentially it has a few constants built in and it also includes age in the equation and once you're greater than 65 , it also includes weight .

So I thought that was interesting . The new CSM . I have to look . I need to do a side by side I haven't done it yet looking at if I put my predictive information in , how close those values are , and so the newer equation looks like it comes from a 2023 article and again breaks it down into females and males , mip and MEP .

It utilizes age BMI and has a number of constants in it to gauge that . So I'm gonna do some side by sides and see what we get there , but I think it really just is something to consider as a data point if you're doing research . I think there's so much .

If you're working with a population that can benefit from respiratory muscle training , I would highly recommend that you push for a case , a case series potentially get one of these devices that you can have an objective number .

So what I was I don't know if I mentioned it before the micro RPM I actually heard from a colleague is no longer , or maybe no longer , being made out of stock . Is it coming back ? I don't know ? So it looks like I'm in search of a new device .

I still have plenty of mouthpieces and such left , but long-term I probably need to have something else ready to go . The presentation at CSM actually had two other devices that looked a little bit more reasonable on price , like $299 and $399 .

So I'm gonna do a little bit of digging on those and maybe , if I purchase one of them , I'll do a YouTube video or Instagram reel or something .

But inspiratory muscle training has so much value and the research supports not only improvement in chest wall mobility , chest wall compliance , oxygen availability , improving pulmonary perfusion , obviously improving inspiratory and expiratory muscle strength and endurance , but it also shows an improvement in aerobic performance .

It helps improve autonomic nervous system , including increasing vagal tone and decreasing sympathetic tone .

So again I have my COVID long COVID people all up in my brain here and can actually help decrease heart rate , improve heart rate variability and in my case , the coolest thing that I saw , I had an adult asthmatic who had other comorbidities , improving hypertension .

She had no change in her medications the time that we were seeing each other and the most profound change that I saw in this patient was her blood pressure . She went from sitting like 160s over 90s from most of our session to 130s over , like low 80s . I mean significant improvement in blood pressure .

So I really do need to write that case up , because I was just so taken aback . I knew how beneficial inspiratory muscle training was , but I didn't really wrap my brain around how much effect it has systemically .

And so , because of that case , I started diving into RMT and heart failure and , sure enough , so much benefit in utilizing respiratory muscle training in our heart failure patients for similar reasons improvement in dyspnea , improvement in pulmonary perfusion , improvement in oxygenation , but also improvement of blood pressure and potentially decreasing systemic vascular resistance .

So just like really freaking cool stuff that you can like just geek out . And I don't know , I get excited about this stuff . So I wanted to talk a little bit about some frequencies and fit training with IMT . So most of the research really has fit training and such around IMT . As I start diving back in I'm going to try to pull more out about EMT .

But a lot of variability across the research . So frequency recommended anywhere between three and seven days a week and anywhere between one and three times a day . So there is some things with the recommended dose that I am concerned about from a patient perspective and ability to perform this . But we'll get into some of the other protocols .

Intensity is usually between 20 and 60% of MIPS . That's like the big variability , and then the average is 20 to 30% of MIPS . Some is listed as 15 to 30 minutes per session . Some is listed as low as five minutes per session . I personally like when it's based on reps versus time . I think it's more palatable for the patient to perform .

It probably takes somewhere between five and 10 , if I have to be honest . And then the type is what kind of trainer that you're using , and so there's a number of different options with trainers .

Some are specific only to inspiratory trainers and some are specific only to expiratory , and then there are some that do both and I am a big proponent of both if you can .

So I think the most common or well-known is the threshold inspiratory trainer , and this is a really great device because you can tweak it to the amount of centimeters per water percent that you're trying to work within . So it's very specific in how much resistance is being applied . I don't believe they have a tool yet that also allows for expiratory .

If they did , that would be spot on .

I just learned about another expiratory device that looks very similar to the inspiratory trainer and , same thing , it's very specific on the dial of how much resistance is being provided , which , in my opinion , is fantastic , because if you're utilizing a MIP , mep device and actually have a number , then you can truly perform or utilize a percent of that MIP , of

that MEP , and be very precise with your protocol . And if you're doing research , this is exactly what you want .

But they don't all do that , and so one of the other trainers that I really like excuse me is the breather , and the breather allows for resistance on inhalation and exhalation , and it has alternate resistance so that you're getting like , if you want to put inhale on three and exhale on five , you can do that .

The downfall to the breather is it's a number and it's not necessarily associated with a specific centimeters of water resistance , so it's a little less precise . I did try to buy an attachment when I was doing my case and it worked okay , but it wasn't super specific . It really had some question whether I was really getting a precise number .

With that being said , you can also utilize basically like an RPE scale or an RPD scale , with the device to determine if inhale or exhale resistance number is appropriate , so you can still document the level of resistance for how much time , for how many weeks , before they're able to tolerate the next change .

So again , I haven't dug super deep recently , but I'm really curious if they're going to make a respiratory muscle trainer that has the ability to assess centimeters of water resistance on both inhalation and exhalation . I think that would be the game changer . I'm trying to remember the name of the other one . They recently followed me on Instagram .

It's like EST1 something , and essentially they're expatory muscle trainers with precise centimeters of water . So I think it's really cool . I'm actually potentially going to try to demo it because I feel like I'm needing a little RMT in my life . One more thing about the breather they also have different devices .

So they're different color devices which allude to different levels of resistance . So they have a pediatric one , they have the white and blue one as the standard and then there's a black one that's made for higher level athletes .

Either way , I think the research supports resistance , muscle training , and it's really coming across multiple diagnoses at this point that it should be added . And then there's these like profound systemic changes that can happen , including improvement in blood pressure , heart rate , autonomic nervous system , like how freaking cool is that ?

So let's talk a little bit about how to perform MIP and MEP with the device that you're using . So , basically , you're going to have a device and it's going to have a mouthpiece . So all of the inhalation , exhalation is pressure through the mouth . So there is some concern with how much leak you get in the cylinder based on the seal of your mouth .

Some of them have some built in components to help decrease the leak . But one of the hardest pieces of it all is to cue your patient not to puff their cheeks , because that can also alter the numbers . So as you're blowing out , not to puff your cheeks is a hard cue . So typically I don't give that cue unless they're really puffing up .

So essentially , you're going to if you're assessing MIP I'm sorry , if you're assessing MIP you're going to inhale to total lung capacity . So you're going to breathe in as deep as you can and then you're going to exhale as forcibly as you can for about two seconds and then that meter should pretty much peter out .

The thing that is really interesting about MIP and MEP is the fact that it is volitional , and so there is a little bit of a learning curve and there's also a how much do you want it right ?

So we , when I was teaching , we would have one student come up and we would do a practice round and then we would let them do a second rep and then on the third rep we would encourage the student and we would cheer the student and that number goes up .

So when you're doing this and you want max effort , cheering on the patient like really encouraging them to do their best is super important . So one of the downfalls to utilizing MIP and MEP is that there's a volitional component to it .

So after doing MEP or whatever you can doesn't matter which one you do first then you're going to switch to MIP and so , on the device , you're going to switch it to the MIP level . You keep the same mouthpiece .

The micro RPM has a flange so that you bite down and it kind of goes into your lips like a mouthpiece so that it helps prevent some of that leak , and then you're going to exhale to residual volume , so you exhale everything out while it's in your mouth and then you suck in as hard and fast as you can and so that's for about again one to two seconds and

then you take the top number that it reads . When you're utilizing these FITT principles you're going to take a percent of that number . So you typically do three trials . Some research says take the average , some say take the max effort .

I believe with MIP and MEP it is max effort Always document all three and then you're going to utilize a percent , like 30% of MIP and that's where you're going to train that person at . With ventilatory endurance specifically , it's on the lower end of that range . So typically if we're trying to improve endurance we're about 20% of MIP .

I don't have percent exhalation numbers . I thought I did but I don't . So next time I do this I'm going to have some more information on our normative data and on our expiratory data . The other thing I wanted to say is that there are different normative ranges for men and women .

Typically , women are about 20% less lower than men , and it's of no surprise , right ? Because if you think even about title volume , size , men and women have very different lung capacities in that realm . And then the other piece of it is that as we age , we're going to see a decrease in mip and mep , and it's a normal sign of aging .

Anything else I feel like I had a couple of more things I wanted to say . I don't know if I went fast on that , yeah , so if you're interested in learning more about respiratory muscle training , if you're thinking about utilizing this in research and you want to set up a meeting , I'm happy to meet with you .

I think if you have the capacity to do research and this is something that you're passionate about and you're working with a population literally across the board , you can be in heart failure , you can be in lung disease , you can be in the COVID world , you can be in neuromuscular spinal cord injury , yambere , ms , als would also be on that list .

So much benefit across the board . There is one more piece that I just want to kind of blanket statement say Before starting respiratory muscle training . It is important for you to educate your patient on normal breathing mechanics , normal breathing sequencing , normal diaphragmatic control .

In my opinion , if your patient is not able to breathe and activate diaphragm comfortably without resistance , and if they're dyspneic at rest , RMT might not be the right intervention .

Cahalin , I believe , was at my CSM talk and in one of the activities we were doing he suggested doing RMT with our pre-lung transplant patient and we were having part of this conversation and he had mentioned a percent and I believe he said if the patient is 70% of normative MIP , then IMT is a go .

So that is another piece of don't hold me to that , like don't write that one down . I need to confirm that percent and I might be emailing him for potential article if he has like a specific data point , because I don't have that data point .

And that's a really good piece because for me , if the patient is dysmic at rest , if the patient is unable to activate the diaphragm , I am likely not going to utilize RMT . If I had a more objective way to determine that , that would be wonderful . So I'm going to keep you posted on that . I'm going to do another one of these . I know this was quick .

It's something I've been wanting to talk about . I didn't have an outline , so hopefully this wasn't all over the place , but I really wanted to start talking about it because I'm excited about it again and this was going to be my path of research and , who knows , maybe this is something that I'm going to be diving into .

If you need to collaborate on anything , shoot me a message . Would love to do that . But this is something that I think can be a game changer in your patient's progress , and I think having like a lot of data points is going to be key , because RMT can literally create such a change in the system and I'm like excited to see where the research goes .

I haven't dove into it in probably three years two , two and a half years but I'm excited about it . So I'm going to come back with RMT . I just want to kind of put a teaser episode out there . Get it on your forefront , start thinking about it . Can you utilize this in your practice ? Have you utilized it in your practice ?

Are you doing this in a research project ? Let me know . I'm like , I'm excited . All right . RMT , IMT , EMT all the same thing , lots of different devices . In order to really do pre-post , you need a MEP and then you need a trainer to actually provide the resistance . So I'm proponent for RMT versus one or the other and I like a device that can do both .

Just personal preference . Actually , I got one more thing why ? Why do I like both ? Why do I want to train both inhalation and exhalation ? Because you need both right . There's so much benefit . And I think if you start thinking about how the diaphragm functions , so the diaphragm is always concentric on inhalation .

So it makes sense to do resistance training with inhalation and when we inhale need to create enough pressure , enough movement with our diaphragm to actually pull air in . So if you're thinking about our restrictive disease patients who have these little lungs and inability to create that pressure change due to compliance , let's see what RMT can do for them .

So I mean , imt is an obvious piece , but I feel like we can't ignore exhalation . So exhalation is really interesting because the diaphragm changes its muscle activation pending what it's doing . When we're in quiet breathing we inhale , it's active . When we exhale it's passive . It's just passive recoil of the lungs and rebound of the diaphragm Very passive .

That's not always the case if we are exercising and breathing heavy , if we're doing heavy lifts and maybe blowing out if we're doing anything we're like , for instance , you're blowing out candles if you are laughing , if you're talking , okay , let's talk about speaking publicly .

I really learned in faculty , when I was teaching two hours at a time , that I was not in faculty shape , not that I wasn't in exercise shape , but being able to speak and exhale and not have to take a break with any of that and then add COVID into the mix with mask on your face . It's going to change your abilities .

So when we're talking , when we're yelling , when we're singing , we are using active diaphragm exhalation and then , lastly , and probably most importantly , when we cough , that is a concentric exhale diaphragm movement and we need power with our cough .

And if we have patients that have increased mucus production , if we have patients with neuromuscular disorders like spinal cord injury , maybe TBI , maybe Guillain-Barre , maybe MS , and they're losing diaphragm strength , they're not gonna be able to clear those secretions Another population we did not talk about , I promise you .

I said we were done and I'm like , see you see how hype I am about this Post-mechanical ventilation . I don't have the percent in front of me , but if you are mechanically ventilated , your diaphragm loses strength pretty much within the hour because it is not actively working when we are being mechanically vented .

A mechanical ventilation goes against our mechanics of our lungs . Our lungs work by creating a negative pressure and sucking air in like a vacuum . Mechanical ventilation is a pushing air in . It is not a normal sequence and your diaphragm's basically on vacation , shouldn't be on vacay , all right .

So if your patient has been mechanically ventilated period , they should be doing some form of RMT breathing exercises at minimum . And if we have prolonged mechanical ventilation , our tracheostomy people , right , like that's another population I can see utilizing IMT at the trach or once they're capped .

Oh so much , so much good , right , so that diaphragm's gonna be weak for both inhale and exhale . So my final statement is if I'm going to choose an intervention for them , personally I would choose a device that can do both inhalation and exhalation , and if you don't have one , then maybe do two devices .

If you wanna be really precise with it , I'm gonna do some digging . I'm gonna do some digging . I'm like really excited about this . We're gonna make this happen , okay now . Now , I think that's all I have .

So just to recap , in order to objectively assess respiratory muscle strength , we wanna utilize MIP and MEP maximal inspiratory pressure or maximal expiratory pressure , and we do that by utilizing a device like the micro RPM , which unfortunately is either going out of business or no longer making a device . But there are other devices that assess MIP and MEP .

Once you have your MIP and MEP you wanna compare it to normative data and then you're gonna utilize a percent usually between 20 and 60% of MIP to perform RMT and you're gonna do that in a gradual way . I do have one more thing . Another reason why I like the breather is I like their protocol . Their protocol is very reasonable .

It's two sets of 10 twice a day . That's very feasible for a patient . I have had patients do it and they're able to maintain it usually for like six to 12 weeks , pending where you wanna put them , versus saying 15 to 30 minutes To me . I think reps is more important . I think reps is safer .

I think anytime we're adding resistance to breathing we have to be careful with how much load we're adding to the patient , especially if they're already compromised and potentially dysmic . But the benefits long-term are amazing Blood pressure , heart rate , autonomic nervous system , six minute walk distance .

And another population we didn't even talk about is our patients with dysphagia . So much benefit with patients that have had stroke in regard to their dysphagia utilizing RMT . So I know I keep saying I'm done , but another little gem pops in .

So , honestly , if you're in the world of research or if you're thinking about doing a research project or you wanna even do a case on one patient with RMT , I'm telling you so much benefit . I'm actually really curious to see where this goes . Over the last five years , the research has blown up across the board .

I would look up Cahalin C-A-H-A-L-I-N , because he has a ton of literature on respiratory muscle training . So lots of research out there specific to different diagnoses and if it's not a specific diagnosis that you are interested in , you can work around the edges and utilize and compare protocols to put into that diagnosis .

Another idea this is just me brainstorming at this point pelvic floor . Another thing that got blown up right before COVID , a colleague and I my good friend and colleague is a pelvic floor therapist and she had this one patient and she was going to be our case and she consented to being a case and she had such significant pelvic floor dysfunction .

She had tightness of the pelvic floor and the first thing that my friend noticed was that her breathing pattern was poorly sequenced . She was paradoxical . She had a history of something lung cancer tumor which was benign , maybe resected like years and years ago . We actually just did a quick assessment .

My pelvic health friend was utilizing EMG and I was teaching her how to diaphragmatically breathe and probably within five to 10 minutes we finally got some good sequencing . The SNF technique was actually , at the end of the day , what got her to be able to remotely sequence without like overthinking .

And as soon as her diaphragm moved in the correct direction so inferiorly on inhale , her pelvic floor relaxed . So the pelvic floor and the diaphragm moved together . It was the coolest thing . And then COVID happened and that whole thing just got cabashed . That's another area that would be amazing to see .

So if any of my pelvic floor therapists want to do RMT and research , like , hit me up , let's do this , because that would be amazing . If it's not already in the research or in the literature , like let's fricking do it , because I will guarantee that you're gonna have great results .

My hypothesis is that it will improve the pelvic floor dysfunction and likely have other benefits that we're not even considering yet . All right , I'm too hype . I'm too hype , we're gonna do this again , because I'm gonna start hitting up the literature again .

I'll be a little bit more , you know , outlined in my approach maybe , and I'd like to talk about this some more .

So I hope that was helpful for you . If it was . If you're doing this , if you're not doing this , if I spark something , hit me up . If you find something cool , share it with me . I love this stuff . Like literally , I am such a nerd and I geek out about this . Yeah , this just got me all hyped .

So we're gonna like , we're gonna do this , we're gonna dive into it . I don't know what I'm doing yet , but I'm doing something and it's gonna be RMT related and we're gonna make it happen , all right . So I hope you all have a wonderful and , whatever you have to do , get after it . We'll see you next time .