Highlights
- •Reflexive cough strength ≤59 L/min may indicate high risk of respiratory infection.
- •Peak cough flow cutoff value improves accuracy of aspiration pneumonia prediction.
- •Objective measurement of reflexive cough strength may predict aspiration pneumonia.
Abstract
Objective
To investigate the clinical usefulness of the peak cough flow generated during the
citric acid reflexive cough test (0.28 mol/L) by determining the appropriate cutoff
values that could accurately predict aspiration pneumonia within the first 6 months
after onset.
Design
Retrospective analysis of a prospectively maintained database.
Setting
University-affiliated hospital.
Participants
Patients (N=163) with first-ever diagnosed dysphagia attributable to cerebrovascular
disease, who had undergone the citric acid reflexive cough test on the same day they
underwent the instrumental assessment of swallowing, such as videofluoroscopy or the
functional endoscopic swallowing test.
Interventions
Not applicable.
Main Outcome Measures
Peak cough flow (L/min) from the citric acid reflexive cough test.
Results
A final 163 patients had full medical records with 6-month follow-up. Receiver operating
curve analysis showed that peak cough flow cutoff values set at 59 L/min were significantly
associated with aspiration pneumonia (area under the curve [AUC] 95% confidence interval
=0.88 [0.83-0.93]). This cutoff value significantly (P<.001) predicted the risk of aspiration pneumonia with an odds ratio of 21.56 (9.62-48.28).
A multivariate regression logistic regression analysis model including initial dysphagia
severity, low body mass index, and decreased level of cognition showed that inclusion
of the peak cough flow from the citric acid reflexive cough test significantly improved
the predictive model of aspiration pneumonia within the first 6 months after onset
(AUC=0.91 vs 0.79).
Conclusions
Those with reflexive cough strength less than 59 L/min may be at high risk of respiratory
infections within the first 6 months after dysphagia onset. Objective measurement
of reflexive cough strength may help to predict those at risk of aspiration pneumonia.
Keywords
List of abbreviations:
AUC (area under the curve), BMI (body mass index), FOIS (Functional Oral Intake Scale), GDS (Global Deterioration Scale), MMSE (Mini-Mental State Examination), mRS (modified Rankin scale), OR (odds ratio), PCF (peak cough flow), ROC (receiver operating characteristic)To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Archives of Physical Medicine and RehabilitationAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Assessment of aspiration risk in stroke patients with quantification of voluntary cough.Neurology. 2001; 56: 502-506
- Acute ischaemic hemispheric stroke is associated with impairment of reflex in addition to voluntary cough.Eur Respir J. 2010; 36: 1383-1390
- Predicting aspiration in patients with ischemic stroke: comparison of clinical signs and aerodynamic measures of voluntary cough.Chest. 2009; 135: 769-777
- Aspiration in patients with acute stroke.Arch Phys Med Rehabil. 1998; 79: 14-19
- Effect of stroke location on the laryngeal cough reflex and pneumonia risk.Cough. 2005; 1: 4
- Formal dysphagia screening protocols prevent pneumonia.Stroke. 2005; 36: 1972-1976
- Processes of care and medical complications in patients with stroke.Stroke. 2011; 42: 167-172
- Dysphagia after stroke: incidence, diagnosis, and pulmonary complications.Stroke. 2005; 36: 2756-2763
- Criteria for extubation and tracheostomy tube removal for patients with ventilatory failure. A different approach to weaning.Chest. 1996; 110: 1566-1571
- Voluntary and reflex cough and the expiration reflex; implications for aspiration after stroke.Pulm Pharmacol Ther. 2011; 24: 312-317
- Cough reflex attenuation and swallowing dysfunction in sub-acute post-stroke patients: prevalence, risk factors, and clinical outcome.Neurogastroenterol Motil. 2017; 29https://doi.org/10.1111/nmo.12910
- Simplified cough test for screening silent aspiration.Arch Phys Med Rehabil. 2012; 93: 1982-1986
- Intra- and inter-rater reliability for judgement of cough following citric acid inhalation.Int J Speech Lang Pathol. 2013; 15: 209-215
- Usefulness of citric cough test for screening of silent aspiration in subacute stroke patients: a prospective study.Arch Phys Med Rehabil. 2015; 96: 1277-1283
- Usefulness of a handheld nebulizer in cough test to screen for silent aspiration.Odontology. 2014; 102: 76-80
- Assessing the laryngeal cough reflex and the risk of developing pneumonia after stroke.Arch Phys Med Rehabil. 1999; 80: 150-154
- ERS guidelines on the assessment of cough.Eur Respir J. 2007; 29: 1256-1276
- Reduced diaphragm excursion during reflexive citric acid cough test in subjects with subacute stroke.Respir Care. 2017; 62: 1571-1581
- Derivation and validation of a clinical system for predicting pneumonia in acute stroke.Neuroepidemiology. 2010; 34: 193-199
- Meta-analysis of dysphagia and aspiration pneumonia in frail elders.J Dent Res. 2011; 90: 1398-1404
- ATS/ERS statement on respiratory muscle testing.Am J Respir Crit Care Med. 2002; 166: 518-624
- Correlation between voluntary cough and laryngeal cough reflex flows in patients with traumatic brain injury.Arch Phys Med Rehabil. 2013; 94: 1580-1583
- Higher cough flow is associated with lower risk of pneumonia in acute stroke.Thorax. 2016; 71: 474-475
- Comparison of cough reflex test against instrumental assessment of aspiration.Physiol Behav. 2013; 118: 25-31
- Functional evaluation: the Barthel index.Md State Med J. 1965; 14: 61-65
- The balance scale: reliability assessment with elderly residents and patients with an acute stroke.Scand J Rehabil Med. 1995; 27: 27-36
- Measurement in neurological rehabilitation.Curr Opin Neurol Neurosurg. 1992; 5: 682-686
- “Mini-mental state”. a practical method for grading the cognitive state of patients for the clinician.J Psychiatr Res. 1975; 12: 189-198
- The Global Deterioration Scale for assessment of primary degenerative dementia.Am J Psychiatry. 1982; 139: 1136-1139
- Cough challenge in the assessment of cough reflex.Br J Clin Pharmacol. 2001; 52: 365-375
- Effect of acute unilateral middle cerebral artery infarcts on voluntary cough and the laryngeal cough reflex.Am J Phys Med Rehabil. 2003; 82: 379-383
- Predictors of aspiration pneumonia: how important is dysphagia?.Dysphagia. 1998; 13: 69-81
- Predictor of rehabilitation outcome for dysphagia.Auris Nasus Larynx. 2014; 41: 294-298
- Risk factors for the onset of aspiration pneumonia among stroke patients in the recovery stage.Nihon Ronen Igakkai Zasshi. 2014; 51: 364-368
- Muscle mass loss is a potential predictor of 90-day mortality in older adults with aspiration pneumonia.J Am Geriatr Soc. 2017; 65: e18-e22
- Influences from laryngeal afferents on expiratory bulbospinal neurons and motoneurons.J Appl Physiol (1985). 1988; 64: 1337-1345
- Influences of superior laryngeal afferent stimulation on expiratory activity in cats.J Appl Physiol (1985). 1988; 65: 385-392
References
- The impact of lesion location and lesion size on poststroke infection frequency.J Neurol Neurosurg Psychiatry. 2010; 81: 198-202
- CDC definitions for nosocomial infections, 1988.Am J Infect Control. 1988; 16: 128-140
- Predictors of pneumonia in acute stroke patients admitted to a neurological intensive care unit.J Neurol. 2007; 254: 1323-1329
- Initial psychometric assessment of a functional oral intake scale for dysphagia in stroke patients.Arch Phys Med Rehabil. 2005; 86: 1516-1520
- A penetration-aspiration scale.Dysphagia. 1996; 11: 93-98
Article info
Publication history
Published online: July 04, 2018
Footnotes
Supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT) (grant number 2017R1C1B5017926). The statistical consultation was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grant number HI14C1062).
Disclosures: none.
Identification
Copyright
© 2018 by the American Congress of Rehabilitation Medicine
