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DSIG: Cough Reflex Testing

Makaela Steel and Shelley Coy - Speech Pathology GCUH

What is Cough Reflex Testing?

Background

The speech pathology department at Gold Coast University Hospital has a strong presence in stroke management.

In 2013, 1,947 stroke and TIA patients received a clinical swallowing assessment.

As we are aware, clinical swallow evaluations performed at the patient’s bedside provide speech pathologists with valuable information regarding oro-motor function and the swallowing mechanism, however results of clinical bedside assessments are known to be a poor predictor of silent aspiration.

Silent aspiration is known to exist in 28-38% of stroke patients who experience dysphagia.

Research Project

In April 2014, the GCHHS speech pathology department was successful in obtaining a $20,000 grant to investigate the implementation of cough reflex testing in initial speech pathology assessments within the stroke population.

This research has been done in conjunction with Griffith University - Gold Coast Campus

Just completed pilot data collection which is being used to support ethics application

Research data collection (RCT) is planned from January to December 2015 - stay tuned for results!

What is Cough Reflex Testing

(CRT)?

CRT is a simple bedside assessment using citric acid inhalation, which can assess the sensory integrity of a patient’s cough as an indicator of silent aspiration risk, when used in conjunction with clinical swallow assessments

Outcomes:

Mr D was transferred the following day (after MBS) to another hospital for ongoing dysphagia management and dysphagia rehabilitation

Unsure of Mr D’s current swallow status

Modified Barium Swallow

Case Study: Mr D

Results as reported by MBS Clinic Speech Pathologist:

  • Mr D presents with moderate oropharyngeal dysphagia characterised by delayed initiation of the swallow reflex, reduced hyolaryngeal excursion and compromised airway protection (? VC function). Silent aspiration occurs during the swallow, and directed cough was ineffective to clear aspirated material.
  • Compensatory strategies including chin tuck and supraglottic swallow technique were used effectively to eliminate aspiration with modified texture diet/fluids.
  • Trialled head turn, chin tuck and supraglottic swallow for thin fluids with nil success - silent aspiration noted for all trials
  • Recommended commencing dysphagia rehabilitation targeting hyo-laryngeal excursion (Shaker) and vocal fold adduction exercises for airway protection

Initial Speech Pathology Assessment Continued...

Any questions??

Modified Barium Swallow

With this patient, the treating consultant requested we continue with our clinical assessment despite cough reflex result and intended clinical guideline given oro-motor was grossly intact.

Clinical swallow assessment:

  • Mild-moderate oro-pharyngeal dysphagia characterised by prolonged bolus formation/transfer for solids (? due to xerostomia from previous ca therapy) and reduced hyo-laryngeal elevation (? secondary to fibrosis to tissue from H&N ca radiation therapy) placing pt at increased risk of aspiration. Coughing was observed post swallow of thin. Chin tuck was trialled with success.

Recommendations:

  • Soft diet and thin fluids with chin tuck for thin fluids

Plan:

  • Urgent MBS to exclude any silent aspiration

Clinical Background - Mr D

Are there any other sites out there investigating the use of cough reflex testing in your clinical swallowing assessments?

Any questions/comments?

  • 57y/o male
  • Transferred from another hospital with mild headache, drooling, slurred speech and generally feeling in a daze.
  • CT Brain: 2cm acute intrapaenchymal hematoma centred on the right basal ganglia region. Intraventricular extension of acute haemorrhage involving the right lateral and 3rd ventricles with no evidence of obstructive hydrocephalus. previous focal infarct of the inferior right cerebellar hemisphere.
  • Phx: CVA (6yrs ago), Hypertension, Hypothyroidism, BOT and throat Ca (6 yrs ago)
  • SHx: Lives at home with son. Current smoker and ETOH abuse (6-8 drinks daily)

Initial Speech Pathology Assessment

Case History:

  • Reported occasional swallowing difficulties characterised by coughing post thin fluids and chronic dry mouth since cancer treatment impacting on mastication of dry foods

Oro-motor:

  • Grossly within normal limits with exception of mildly reduced lingual strength bilaterally

Motor Speech:

  • Nil evidence of dysarthria
  • Moderate dysphonia characterised by reduced volume, breathy and rouogh quality quality h/e Mr D reported nil difference in voice from pre-morbid. Mr D reported voice changes occurred during H&N Ca tx.

Cough Reflex Testing results:

  • Trial 1, 2 & 3 – absent – nil response
  • Nil response to all stimuli – hypothesised whether this was due to reduced sensation as a result of previous radiation therapy to BOT/pharyngeal region 6 yrs earlier for Ca treatment

Cough Reflex Testing

Aims of the Research

To determine if introducing cough reflex testing as part of a clinical pathway will reduce the incidence of aspiration pneumonia and consequent average length of stay for acute stroke patients.

To evaluate whether it is feasible to implement cough reflex testing as part of standard initial swallowing assessments for all new stroke patients, including the patient’s tolerance and clinician satisfaction.

Clinical Pathway

  • If the patient produces a positive result, proceed with oral trial at the bedside.
  • If the patient produces positive but weak results, proceed with oral trials but refer for a modified barium swallow (MBS) as soon as possible as bedside indicators of aspiration may be inaccurate.
  • If the patient produces a negative result, do not proceed with oral trials. An MBS is required prior to any oral trials at bedside as indicators of aspiration are likely to be inaccurate.

How to perform CRT

Citric acid is administered for a maximum of 15 seconds via a facemask using a nebuliser or medical air (not oxygen). Patients are instructed “I’m going to give you some air to breath, keep breathing normally”. The test is repeated three times with a rest interval between each presentation. Two positive responses out of three trials are considered a positive result

Scoring of CRT

Strong Response = Two or more strong coughs

Weak Response = Two or more weak coughs

Absent Response = One or no cough

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