When foreign particles enter a healthy airway, the mucociliary escalator (movement of mucus up and out of the respiratory tract) and cough work in consort to help clear and protect the lower airways. When a person aspirates during eating, and food or liquid passes below the vocal folds, a cough reflex should help to expel the material. But for individuals with respiratory muscle weakness or severe pulmonary disease, coughing may not generate sufficient intrathoracic and abdominal pressures for the peak cough expiratory flow necessary to effectively clear airway secretions.  

An adequate cough requires a deep inspiration; forceful expiration against a closed glottis (vocal folds); and subsequent opening of the glottis, producing sufficient velocity of airflow on exhalation to shear mucus attached to the airway walls into the air stream.

Excessive or ineffective coughing isn’t desirable either because it can lead to other problems, such as headache, vocal fold trauma, reflux, urinary incontinence, and fatigue of already weakened muscles.

In neurodegenerative conditions, such as Parkinson’s disease, weakness or in-coordination of the oral-pharyngeal muscles and respiratory muscles may act together to reduce swallowing efficiency and safety. If a patient aspirates (material enters the airway) when eating or drinking, and cough is absent or weak and insufficient to clear material from the airway, aspiration pneumonia or recurrent lung infections may be the result.

Pulmonary hygiene refers to exercises and procedures that help to clear your airways of mucus and other secretions and may be an important treatment goal for patients with documented aspiration secondary to dysphagia (swallowing impairment).

Techniques that assist with lung clearance include manual and device interventions, and they have been used effectively for over 30 years helping to improve airflow velocity and cough efficiency. Manual methods which were commonly used during the polio epidemic of the 50’s have been largely replaced by device interventions, but manual techniques still have a role in pulmonary hygiene, can be easily taught, and can be used alone or in conjunction with a device intervention such as a respiratory muscle trainer (RMT).

The Active Cycle of Breathing Technique is used to clear secretions, and there are three parts to it:

Breathing Control- Deep Breathing- and Huffing


Breathing control is used to relax the airways and relieve symptoms such as tightness or wheezing associated with vigorous coughing.

  • Rest one hand on your stomach and allow your shoulders to drop down
  • Breathe quietly and gently. As you breathe in your stomach should rise slightly, it should fall as you breathe out – do not force the air out.

Deep breathing is used to get air behind the sputum stuck in small airways

  • Relax your upper chest
  • Breathe in through your nose slowly and deeply (“smell the coffee”)
  • Repeat 3 – 4 times, if you feel lightheaded go back to relaxed breathing

Breathe out gently through purse lips as long as you can (“blow out the candle”) – don’t force the air out. Purse lip breathing (exhaling through rounded lips) creates back pressure and helps to open the alveoli where oxygen exchange occurs.

Once you have done deep breathing exercises, go back to breathing control again to make sure your airways are relaxed. Sometimes when sputum is difficult to clear you may need to go back to the deep breathing exercises a second time before huffing.

Deep breathing can also be done using an, inspiratory-expiratory flow resistant RMT device like the Breather® . You can perform deep breathing with the device set at lower resistance levels or set at higher resistance levels if strengthening the respiratory muscles is also your goal. A manometer (a pressure gauge) attached to your device can provide visual feedback that helps the user judge their level of effort and establish more targeted training.


Huffing moves sputum from the small airways to the larger airways, from where they are removed by coughing.

  • Take a medium sized breath in and squeeze the breath out by contracting your abdominal muscles and keep your mouth and throat open as if saying /HA-HA-HA/but without voice.
  • Take a large breath in and squeeze the air out, this time expectorating any mucus or sputum.
  • If you don’t produce any sputum with 2 attempts but this technique triggers coughing, try to stop coughing by using your breathing control.
  • Allow your breathing to settle with breathing control and then repeat the cycle until your chest feels clear.

Huffing can also be a helpful technique for voice patients or chronic cough patients, who report phlegm or mucus as a trigger for coughing.

Huff is a forced, but not harsh maneuver that can facilitate airway clearance, and because it doesn’t involve harsh vocal fold contact, it may be a good technique for patients with weak or impaired vocal fold function.

Active cycle of breathing  can also be combined with postural changes, such as a pro gravity positioning or side-lying to facilitate clearance, or can include manual percussion with hands alone, a flexible face mask or cup, or a small mechanical vibrator/percussors can be used.

So, although device interventions have gained in popularity and gradually replaced many manual methods, there is still some benefit associated with manual techniques.

Pulmonary Hygiene and Aspiration

Prevention of aspiration is always a primary goal of dysphagia treatment, but, in some instances, despite therapeutic interventions, a patient may continue to aspirate food or liquid, or even their own secretions, and in those instance, instructing the patient and family in pulmonary hygiene strategies may be a worthwhile focus.

For individuals with a neurodegenerative disease diagnosis, and the likelihood that swallowing function may be affected, education regarding pulmonary hygiene strategies early in treatment  in conjunction with  use of a respiratory muscle strengthening device such as The Breather®, may be a  worthwhile approach that focuses on prevention and treatment.

Medical Advice Disclaimer: The information contained herein should not be construed as medical advice, and is not intended to replace the medical advice of your physician or other licensed healthcare provider in your state. You should continue to consult your physician for matters regarding your health, and report any new cough or fever. Follow CDC guidelines to prevent the spread of CORONA virus.

Congratulations to the 2020 Voice Aerobics Graduate Student Scholarship Recipient

Amanda Dolan, a first-year graduate student at New York Medical College, Westchester, NY is this year’s scholarship recipient. Amanda was selected from a field of over 100 applicants, many with personal stories of being inspired by a family member challenged with a communication disorder.

It is fitting, perhaps, that this year at a time when life feels a bit upside down for all of us, that Amanda is the scholarship recipient, because she knows first-hand about perseverance and resilience.

In 2011, Amanda suffered a traumatic brain injury, and activities that she had previously taken for granted became her new daily challenges. She credits the kindness and compassion of her speech therapist as an important component of the treatment that helped her resume a more normal life, saying:  “her encouragement and commitment to my care gave me hope, enabled my recovery, and instilled in me the desire to one day provide passionate and patient-oriented care.”

To read more about Amanda and the Voice Aerobics graduate student scholarship visit: https://voiceaerobicsdvd.com/student-scholarship/

June Aphasia Awareness Month

There is perhaps no communication impairment that is more isolating than aphasia. Aphasia makes understanding or using language difficult, and is often a symptom following a stroke or other brain injury. Because aphasia occuring after stroke is sudden, individuals and their family members may be unexpectedly thrust into a world where communication, something we all take for granted, is now a daily struggle. Recovery from aphasia is often slow, and to some degree, for many people will be a life-long challenge.

Voice of Hope for Aphasia is a non-profit organization located in Tampa, Florida, providing community-based programs for people with aphasia and their families. When the Covid pandemic restricted physical contact, they were required to make a quick change, and they moved their programs to an online format. Fortunately, their members adapted to the change and their heartfelt messages illustrate the importance of social connection:

“The online sessions have helped me to feel much less isolated during COVID-19. They help me stay positive, laugh and practice, practice, practice!!!” – person with aphasia

“Getting connected with Voices of Hope for Aphasia has been an absolute blessing.” – wife of a person with aphasia

“The online sessions are great – you have all thought ahead of what to do for us.” – person with aphasia

If you or someone you know has aphasia, I encourage you to visit Voices of Hope for Aphasia website and learn more about their program, or make a donation to support all of the wonderful things they are doing to support people with aphasia in Florida and around the country.


My MissionTo enlist individuals in their treatment, and help them express their personality & spirit through voice. To educate  and empower. Mary Spremulli, MA, CCC-SLP * FiTOUR® Group Exercise Instructor * Voice Aerobics® A Whole Body Approach to Voice Practice

Voice Aerobics the heART and Science of Voice Practice