Protocol extracted from the book
The translators, Austin and Irwin with their selfless and dedicated work which enabled this work to transcend borders.
To Marchesan Irene, Justin and Danile Hilton Andrade because they always credited our work.
To Licia Paskay and Patrick McKeown, whose extensive experience in this area conducted an in depth and detailed work on the scientific review of the book.
To all of you my greatest admiration and respect!
Speech therapy is defined as the specialty and academic discipline that studies the development, alterations and contrasts of human communication relating to hearing, writing, language, speech, voice, orality and the cervical motor system. In order to develop, empower, rehabilitate and improve the communication patterns 1,2, this speciality is divided into specific areas of activity such as audiology, speech, orofacial myology and language/learning 1.
Orofacial Myology – OM is the field of action of the speech therapist that promotes health and implements prevention of disorders of the orofacial myofunctional system or stomatognathic system, but also diagnoses and treats congenital or acquired disorders of this system during the different stages of life, from conception to aging 3. The stomatognathic system corresponds to an anatomically and physiologically integrated unit, coordinated by the nervous system which integrates skeletal structures – muscles, tendons, fascia, ligaments; neural, vascular, glandular, and exoskeletal elements; skin, mucosa and periodontal structures, among others 4. Moreover, it is integrated organically and functionally with systems that also form
part of the digestive, respiratory and sensory nervous systems. The olfactory, gustatory, auditory and visual sensory activities are included in these systems, allowing a close functional and reciprocal relationship 4.
The morphology and synergism of these components allow the execution of the stomatognathic functions. Therefore, the orofacial system will affect its own functions, along with others that are associated or linked to those functions, such as oronasal breathing 4. The quiet oronasal breathing, from the physiological perspective (nasal breathing) and pathophysiological perspective (oronasal), has been of interest to the speech therapists specializing in OM for many years. In order to carry out studies in this area breathing was always a consideration and to consult the texts of authors such as Krakauer 5, Marchesan 6, and Francesco 7, amongst others, required gathering further information from other studies.
While doing bibliographic research, my great surprise was that the oronasal breathing was not a concern only for the speech therapist, but professionals of many other specialties have also discussed this issue for decades. An impressive range of data was found in these investigations, once again reaffirming the results obtained from the studies and urging a concern for organizing the causes and the consequences of oronasal breathing. However, during the early years of studying as a young professional, my main interests were the patients and their rehabilitation, instead of looking for an appropriate respiratory modality and determining if a patient breathes through the mouth or not. Other approaches rather than breathing correction were tried at first, initially, carrying my research in the opposite direction.
When the observations didn’t show any progress in the patients, I commenced to correct my search. In those moments, I began to realize what was wrong, so I decided to revise the initial patient assessments and again consult with several other authors. Then I found methods, interrelating data and facts that clarified my study. I realized, among other things, the importance to instruct the patients to keep their mouths closed, or to perform an exercise to improve the tone of their lips. However, this was not enough when there were already structural alterations as malocclusions, or when the origin of the oronasal breathing was anatomical, inflammatory or infectious. In these cases the patient required a team of specialists to continue the treatment.
One of the phrases that impressed me was made by Dr. Marchesan: “Regarding diagnosing and treating oral breathing problems, it is essential for the audiologist to understand the anatomy and physiology of the respiratory system.” You must also know the pathophysiology of respiration and its impact on the stomatognathic system and organism as a whole.
The rethinking of our intervention will lead, in many cases, to resume the steps ignored or dismissed, as in the case of the evaluation. While analyzing phonoaudiologic respiratory assessment mode, several questions arose: if respiratory intake of air through the mouth is so altered, why do we only consider the air outlet? When the patient keeps the mouth open all the time, does that mean he or she is breathing orally? Does an obstruction of the upper airway inhibit 100% of nasal inspiration? Does the air outlet always have to be symmetrical? And, most importantly, is it enough to evaluate only the output of nasal air and diagnose the patient as an oral breather?
Looking for answers, I found the instrument created by Barreto8, the oronasal plate, which was initially modified with the help of my colleague Fara Maldonado, in 2012. This modified oronasal plate allows the examiner to assess not only the output of nasal air, but also the oral air output in a patient with an habitual open mouth, offering a little more information for a better diagnosis.
The Oronasal Plate Adapted by Susanibar – OPAS was presented at the “V Brazilian Meeting of Orofacial Motricity”. From that moment on it became necessary to have a protocol for the use of the OPAS. Several authors were consulted; in addition I was fortunate to be guided by professional experts in the field such as Daniele Andrade, Hilton Justino and Irene Marchesan. The result was the creation of the assessment instrument called “Protocol on the Phonoaudiological Assessment of Breathing with Scoring – PROPABS”. This is organized into four parts: anamnesis, clinical examination, analysis of results and conclusions / conduct.
However, the creation of PROPABS raised the need for a manual that addresses its application. In partnership with Cynthia Dacillo, I embarked on this project and decided to produce a text that not only describes the application, but offers the reader the theoretical support based in evidence on knowing exactly why and how certain features should be evaluated, as well as offering the parameters for normalcy.
All these elements helped to shape the book “Phonoaudiological Assessment of Breathing”. This work is divided in two parts: Part one has a brief theoretical framework underlying the assessment of respiration, including an extensive literature review that addresses breathing and general appearance of the functions of the nose, the respiratory rate and its mode in different activities and finally the causes of the oronasal breathing when alterations were involved. Part two describes in detail each of the segments of the protocol, guiding the professional on how to record the patient’s history, carry out the morphological and functional assessment, and perform the orofacial evaluation by applying the OPAS and concludes with guidance on how to evaluate the results, providing a differential diagnosis and suggesting procedures to follow.
It should be noted that this work has already been published in Brazil in 20139, but the English version was updated and revised and has more scientific evidence, figures and pictures. Likewise, the oronasal plate was perfected obtaining more accurate evidence.
I’m sure that the study of this book will allow the examiner to serve the patient better, which ultimately is our primary goal.
1. SBFa, Comitê de Motricidade Orofacial. Documento oficial 01/2001 do Comitê de Motricidade Oral da Sociedade Brasileira de Fonoaudiologia (SBFa), 2001.
2. Susanibar F, Parra D. Diccionario terminológico de Motricidad Orofacial. EOS: España. 2011
3. SBFa, Comitê de Motricidade Orofacial. Documento oficial 23/09/2013 do Comitê de Motricidade Oral da Sociedade Brasileira de Fonoaudiologia (SBFa), 2013.
4. Susanibar F, Douglas C, Dacillo C. Fundamentos fisiológicos de la Sensibilida d del Sistema Estomatognática In: Susanibar F, Parra D, Dioses A (Coordinadores). Motricidad Orofacial: Fundamentos basados en evidencias. Madrid. EOS, 2013.
5. Krakauer, Di Francesco, Marchesan IQ. Respiración Oral. São Jose dos Campos: Pulso Editorial, 2003.
6. Marchesan IQ. Avaliação e Terapia dos Problemas da Respiração. In: Marchesan IQ. Fundamentos em Fonoaudiologia: Aspectos Clínicos da Motricidade Oral (pp.29-43). 2ª ed. Rio de Janeiro: Guanabara Koogan; 2005.
7. Di Francesco RC. Respiração oral: a visão do otorrinolaringologista. J Bras Fonoaudiol 1999; 1:56-60.
8. Barreto, ACYR. Respiração oral proposta de um novo instrumento para avaliação do modo respiratório [tese]. Piracicaba (SP): Universidade Estadual de Campinas; 2003.
9. Susanibar F; Dacillo C. Avaliação da Respiração: Protocolo de Avaliação Fonoaudiológica da Respiração com Escores – PAFORE. São Jose dos Campos: Pulso Editorial, 2013.
PROLOGUE TO THE ENGLISH EDITION
It’s probably a common occurrence in the life of any clinician to wish to have an adhoc, specific test or protocol to objectively assess and evaluate specific aspects of the patient. It happens to me, quite often. These specific protocols are not always commercially available and it takes great dedication, patience, determination and countless hours of hard work to create one. That’s what makes this manual so precious: it identified a need, common to thousand of clinicians worldwide, and it addressed that need in a protocol with a clear and easy-to-follow format. Moreover, economic concerns often prevent patients from seeking the assessment of medical specialists, who often manage technologically sophisticated and expensive “machines”. Clinicians working in small clinics or in private practice also might not have available laryngometers, naso-endoscopic probes and the like.
Endeavors like this manual and protocol are always a team effort, and Franklin Susanibar and Cynthia Dacillo are the conductors of a large orchestra of experts, whose knowledge is elegantly woven into a very useful and long overdue assessment protocol to measure breathing. Since most orofacial, pharyngeal and laryngeal functions depend on proper breathing such a protocoll and manual are vital for proper therapy but rarely is a protocol for speech therapists and orofacial myofunctional therapists available and easily applied like the PROPABS, the Protocol for the Phonoaudiological Assessment of Breathing with Scores. In addition, Franklin Susanibar adapted a nasal mirror to quantify oral and nasal breathing simultaneously
and to be scored within the protocol, a brilliant idea using a simple, versatile and affordable device.
I had the privilege of receiving and using this protocol in its earlier format (the Portuguese version called PAFORE) and since then I have been hoping for an english version of it. I know the need for this protocol is great, and it can benefit thousands of therapists helping their patients, by finally identifying the cause of many orofacial problems, stemming from insufficient to non habitual nasal breathing. Proper nasal breathing is the fundamental function upon which all the other orofacial functions depend.
It has been again an honor and a privilege to collaborate at the english edition of this manual, describing the PROPABS, and it’s my hope that it becomes the absolutely needed tool for evaluation of breathing, both in clinical practice and in research.
Licia Coceani Paskay
Orofacial Myofunctional Therapist
President of the Academy of Applied Myofunctional Sciences (AAMS)
Los Angeles, California
PROLOGUE TO THE SPANISH EDITION
The examination of patients breathing has been the most important concern of specialists in the area of speech therapy in Orofacial Motricity worldwide.
We know that when quiet breathing is not performed by the nose, but by means of the mouth, or performed by the nose and mouth at the same time, that leads to various disorders such as inappropriate position of the lips and tongue, as well as of the head and shoulders, and other body alterations such as decreased facial and oral muscle tone. The mobility of the phonoarticulatory structures is altered along with symptoms such as: decreased sense of smell and/or taste; accumulation of saliva in the oral cavity; in some cases a salivary incontinence (drooling); eyes showing dark circles and an apparent aspect of fatigue; snoring and/or apnea; chewing and swallowing inadequately, even speech may be inaccurate… all mainly caused by decreased muscle tone.
Likewise, many of the alterations of occlusion and even craniofacial growth have been identified as sequels to oral or oronasal breathing. Inclusively, we can find in literature citations the problems of learning at school, mainly caused by the lack of attention, that can be strongly related to sleep difficulties manifested in sleepless nights, little sleep, or even apneas, causing the amount of oxygen circulating in the body to drop.
For all these reasons and even for others less cited in the existing literature but no less important, much has been written about the work that needs to be developed to regain nasal breathing. Of course, this is done jointly by physicians, dentists, speech therapists and in some cases with the assistance of a psychologist.
The most important problem is that sometimes the speech therapist knows how to rehabilitate breathing, but has no major parameters on how to perform the evaluation. Considering this difficulty, Susanibar has written an efficient and important “Protocol manual on the phonoaudiological assessment of breathing with scoring – PROPABS”, also adapting a plate, which, at an angle of 90°, allows the measurement of the amount of air passing through the nose and mouth at the same time.
What’s more, the author of the protocol, along with Cynthia Dacillo, produced a book that details the use of the protocol and plate, offering parameters between what is appropriate, according to several researches mentioned in this book, and what is pathological.
The book comprises two parts: in the first the authors write about the foundations for the evaluation, such as the functions of the nose during respiration; respiratory type and mode; respiratory disorders and oronasal breathing mode. The second part deals with the assessment, providing data of “what and why” performing certain questions in the anamnesis is relevant, through the structural and functional assessment and concluding with data about the final presumptive diagnosis.
This is a book that every health professional should have regarding the importance and fundamental need of breathing well, as breathing is life and breathing through the nose will allow a higher quality of life.
I congratulate the authors for the brilliant idea of creating a scoring protocol and application manual for the evaluation of breathing, which is indeed the basis of speech language therapy.
Dr. Irene Q. Marchesan
Speech therapist Clinic from 1978
Director of CEFAC from 1983
Specialist OM by CFFa
Masters in Communication Disorders 1989
PhD in Education 1998