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Original Research: COUGH |

Predicting Aspiration in Patients With Ischemic Stroke: Comparison of Clinical Signs and Aerodynamic Measures of Voluntary Cough

Carol A. Smith Hammond, PhD; Larry B. Goldstein, MD; Ron D. Horner, PhD; Jun Ying, PhD; Linda Gray, MD; Leslie Gonzalez-Rothi, PhD; Donald C. Bolser, PhD
Author and Funding Information

*From the Durham Veterans Affairs Medical Center (Dr. Smith Hammond), Durham, NC; the Center for Cerebrovascular Diseases (Dr. Goldstein), and the Department of Radiology (Dr. Gray), Duke University, Durham, NC; Institute for the Study of Health (Drs. Horner and Ying), University of Cincinnati Academic Health Center, Cincinnati, OH; Brain Rehabilitation Research Center (Dr. Gonzalez-Rothi), Gainesville VAMC, Gainesville, FL; and the Department of Physiological Sciences (Dr. Bolser), University of Florida, Gainesville, FL.

Correspondence to: Carol Smith Hammond, PhD, Durham VAMC, 508 Fulton St, No. 126, Durham NC, 27705; e-mail: smith390@mc.duke.edu


This study was supported by the Department of Rehabilitation, Research and Development Service, Veterans Affairs National Headquarters.

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).


Chest. 2009;135(3):769-777. doi:10.1378/chest.08-1122
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Background:  Clinical signs often fail to identify stroke patients who are at increased risk of aspiration. We hypothesized that objective measure of voluntary cough would improve the accuracy of the clinical evaluation of swallow to predict those patients who are at risk.

Methods:  A comprehensive diagnostic evaluation was completed for 96 consecutive stroke patients that included cognitive testing, a bedside clinical swallow examination, aerodynamic and sound pressure level measures of voluntary cough, and “gold standard” instrumental swallowing studies (ie, videofluoroscopic evaluation of swallow [VSE] or fiberoptic endoscopic evaluation of swallow [FEES]). Stroke severity was assessed retrospectively using the Canadian neurologic scale.

Results:  Based on the findings of VSE/FEES, 33 patients (34%) were at high risk of aspiration and (66%) were nonaspirators. Clinical signs (eg, absent swallow, difficulty handling secretions, or reflexive cough after water bolus) had an overall accuracy of 74% with a sensitivity of 58% and a specificity of 83% for the detection of aspiration. Three objective measures of voluntary cough (expulsive phase rise time, volume acceleration, and expulsive phase peak flow) were each associated with an aspiration risk category (areas under the curves were 0.93, 0.92, and 0.86, respectively). Expulsive phase rise time > 55 m/s, volume acceleration < 50 L/s/s, and expulsive phase peak flow < 2.9 L/s had sensitivities of 91%, 91%, and 82%, respectively; and specificities of 81%, 92%, and 83%, respectively for the identification of aspirators.

Conclusion:  Objective measures of voluntary cough can identify stroke patients who are at risk for aspiration and may be useful as an adjunct to the standard bedside clinical assessment.

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