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Assessment of aspiration risk in stroke patients with quantification of voluntary cough

From Duke University and Durham Veterans Affairs Medical Center (Drs. Smith Hammond, Goldstein, and Gray) and Duke Center for Cerebrovascular Diseases, Department of Medicine (Neurology), and Center for Clinical Health Policy Research (Dr. Goldstein), Durham, and Department of Dental Ecology, University of North Carolina–Chapel Hill (Dr. Zajac), NC; and Department of Physiological Sciences (Drs. Davenport and Bolser), University of Florida, Gainesville.

Address correspondence and reprint requests to Dr. C.A. Smith Hammond, Durham VAMC, AUD/SP 126, 508 Fulton Street, Durham, NC 27705; e-mail: smith390{at}mc.duke.edu

BACKGROUND: Dysphagia and subsequent aspiration are serious complications of acute stroke that may be related to an impaired cough reflex. It was hypothesized that aspirating stroke patients would have impaired objective measures of voluntary cough as compared with both nonstroke control subjects and nonaspirating stroke patients.

METHODS: Swallowing was evaluated by standard radiologic or endoscopic methods, and stroke patients were grouped by aspiration severity (severe, n = 11; mild, n = 17; no aspiration, n = 15). Airflow patterns and sound pressure level (SPL) of voluntary cough were measured in stroke patients and in a group of normal control subjects (n = 18). Initial stroke severity was determined retrospectively with the Canadian Neurological Scale.

RESULTS: All cough measures were altered in stroke patients as a group relative to nonstroke control subjects. Univariate analysis showed that peak flow of the inspiration phase (770.6 ± 80.6 versus 1,120.1 ± 148.4 mL/s), SPL (90.0 ± 3.1 versus 100.2 ± 1.6 dB), peak flow of the expulsive phase (875.1 ± 122.7 versus 1,884.1 ± 221.6 mL/s), expulsive phase rise time (0.34 ± 0.1 versus 0.09 ± 0.01 s), and cough volume acceleration (5.5 ± 1.3 versus 27.8 ± 3.9 mL/s/s) were significantly impaired in severe aspirators as compared with nonaspirators. Aspirating patients had more severe strokes than nonaspirators (mean Canadian Neurological Scale score 7.7 ± 0.7 versus 9.8 ± 0.3). Multivariate logistic regression found only expulsive phase rise time values during cough correlated with aspiration status.

CONCLUSION: Objective analysis of cough may provide a noninvasive way to identify the aspiration risk of stroke patients.

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