Voluntary Cough Effectiveness and Airway Clearance in Neurodegenerative Disease

Deglutologist Practices and Perceptions of the Penetration-Aspiration Scale: A Survey Study

Successful dysphagia management requires accurate, succinct diagnosis and characterization of swallowing safety impairments. However, the Penetration-Aspiration Scale (PAS) remains the only available tool developed exclusively for assessment of airway protection. To best support efforts to advance the field's understanding of swallowing safety, it is crucial to understand current clinician practice patterns, perceptions, and accuracy regarding the PAS. A 46-item survey was developed and distributed to deglutologists internationally examining: (1) Demographics; (2) Scale Practices; (3) Swallowing Safety Priorities; (4) Scale Perceptions; and (5) Accuracy. The first four sections consisted of questionnaires. In the optional fifth section, respondents were asked to score five videos of swallows collected via videofluoroscopy and previously PAS-scored by two trained raters. In total, 335 responses were analyzed. The majority of respondents self-reported PAS training (84%); 90% of untrained respondents were receptive to training. Respondents reported using the PAS "always" (40%) or "frequently" (29%), and that the PAS carries "a great deal of" weight in assessment (40%). Reported application of the PAS was heterogeneous, with the most common approach being "single worst score per unique presentation" (45%). Most respondents (64%) prioritized a parameter not captured by the PAS. Untrained respondents were significantly more confident with PAS ratings than trained respondents (X2 = 7.47; p = 0.006). Of 1460 PAS ratings provided, 364 of them were accurate (25%) when compared to ratings by trained lab members. Results of this survey reflect ubiquitous use of the PAS, unmet needs for assessment of swallowing safety, low accuracy despite generally high confidence, and heterogenous training that does not correspond to confidence. This emphasizes the need for additional training in clinical application of the PAS as well as development of novel metrics to optimize assessments of swallowing safety.

A Preliminary Study of Voluntary Cough Motor Performance and Learning With Skill Training and Biofeedback

PURPOSE

Sensorimotor cough skill training (CST) has been shown to improve cough strength, as well as facilitate changes during training (i.e., motor performance) and generalization to untrained tasks (i.e., motor learning). However, there is a gap in our understanding of the effects of voluntary CST (without sensory stimuli) on motor performance and learning. Furthermore, the contribution of physiologic factors, such as lung volume, a driver of cough strength in healthy adults, and treatment-specific factors, such as biofeedback, remains unexamined.

METHOD

Twenty individuals with Parkinson's disease (PD) completed pre- and post-CST single voluntary, sequential voluntary, and reflex cough testing. Participants were randomized to biofeedback or no biofeedback groups. They completed one CST session involving 25 trials of voluntary coughs, with the treatment target set 25% above baseline peak flow. Participants were instructed to "cough hard" to exceed the target. In the biofeedback group, participants received direct visualization of the target line in real time.

RESULTS

Cough peak flow showed positive improvements in motor performance (β = .02; 95% credible interval [CI]: 0.01, 0.03) and learning (β = .26; 95% CI: 0.03, 0.47). Changes in lung volume from pre- to post-CST did not predict treatment response. No differences in treatment response were detected between the biofeedback groups.

CONCLUSIONS

A single session of voluntary CST improved voluntary cough motor performance and learning. Although lung volume increased during CST, changes to lung volume did not predict treatment response. These findings demonstrate the potential of voluntary CST to improve motor performance and motor learning among individuals with PD and cough dysfunction.

SUPPLEMENTAL MATERIAL AND OPEN SCIENCE FORM

https://doi.org/10.23641/asha.25447444.

Cough Correlates of Functional Swallow Outcomes in Atypical Parkinsonism

BACKGROUND

Swallow and cough impairments lead to aspiration and reduced clearance of aspirate material. Both behaviors are impaired in Parkinson's disease, but it is unknown whether a similar relationship of dysfunction exists in forms of atypical Parkinsonism (APD). Elucidating this association in APD may lead to early, comprehensive airway protection treatment.

OBJECTIVES

We tested the hypotheses that swallow deficits in APD are associated with impaired cough and that airway protective dysfunction is associated with longer disease duration.

METHODS

Swallowing difficulty was described by 11 participants with APD. Penetration-Aspiration Scale (PAS) and DIGEST scores for thin liquid trials were extracted from medical records of videofluoroscopic swallow study reports. Voluntary and capsaicin induced-reflex cough measures of flow, volume, and timing were analyzed.

RESULTS

While most participants did not have post-swallow residue, ~80% received abnormal PAS scores and reported swallowing difficulty. Those with abnormal PAS scores had lower voluntary cough expired volume (P = 0.037; mean rank difference = 5.0); lower reflex inspiratory flow rate (P = 0.034; mean rank difference = 5.5); and longer reflex expiratory flow rise time (P = 0.034; mean rank difference = 5.5). Higher PAS scores and reduced reflex cough volume acceleration were significantly correlated (r = -0.63; P = 0.04) and longer disease duration predicted larger voluntary cough expired volume (R2  = 0.72) and longer flow rise times (R2  = 0.47).

CONCLUSIONS

As swallow safety worsens, so might the ability to clear the airways with effective cough in in APD; particularly with longer disease duration. Assessing cough in conjunction with swallowing is important for informing airway protection treatment plans in APD.

Motor Performance During Sensorimotor Training for Airway Protection in Parkinson's Disease

INTRODUCTION

Cough dysfunction is highly prevalent in Parkinson's disease (PD) and associated with pneumonia, a leading cause of death. Although research suggests that cough can be volitionally upregulated, patterns of improvements that occur during cough skill training and potential correlates remain unexamined. Therefore, we sought to characterize changes to peak flow during cough skill training, examine whether early variability predicted motor performance trajectories during treatment, and explore the relationship between peak flow during cough skill training and motor learning on a similar but untrained task (i.e., reflex cough testing).

METHOD

This secondary analysis of treatment data from a randomized controlled trial included 28 individuals with PD who participated in five sessions of sensorimotor training for airway protection (smTAP). During this novel cough skill training, participants completed 25 repetitions of coughs targeting peak flow 25% above their baseline. Reflex and voluntary cough testing was performed pre- and posttreatment. Bayesian multilevel growth curve models provided group and individual-level estimates of peak flow during training.

RESULTS

The magnitude and consistency of peak flow increased during cough skill training. Variability in peak flow during the first treatment session was associated with greater improvements to peak flow in later sessions. There was no relationship between changes to peak flow during cough skill training and motor learning.

CONCLUSIONS

Individuals with PD improved the strength and variability of cough peak flow during cough skill training. These findings provide a clinically relevant characterization of motor performance during cough skill training and lend insight into potential correlates to guide future treatment paradigms.

Preoperative respiratory strength training is feasible and safe and improves pulmonary physiologic capacity in individuals undergoing cardiovascular surgery

Objective

To determine the safety, feasibility, and physiologic impact of a preoperative respiratory strength training (RST) program in individuals undergoing elective cardiac surgery (CS).

Methods

Twenty-five adults undergoing an elective CS at an academic hospital setting enrolled and completed RST 5 days/week (50 repetitions, 50% training load, ≥3 weeks) at home via telehealth in this open-label prospective cohort study. RST adherence, telehealth attendance, and adverse events were tracked. Pre- and post-RST outcomes of maximum expiratory pressure (MEP), maximum inspiratory pressure (MIP), voluntary cough spirometry, and patient-reported dyspnea were collected. Descriptive analyses and Wilcoxon signed rank-tests were performed.

Results

Two participants (9%) did not complete the prescribed RST program. No significant RST-related adverse events occurred. Treatment adherence for all enrolled participants was 90%, and telehealth attendance was 99%. Of the CS patients who completed the prescribed program (n = 23; 91%), treatment adherence and telehealth attendance were excellent (98% and 100%, respectively). Significant increases in primary outcomes were observed: MEP mean change, +15.4 (95% confidence interval [CI], +3.4 to +27.3, P < .007); MIP mean change, +14.9 (95% CI, +9.4 to +20.4, P < .0001). No statistically significant differences in voluntary cough or perceived dyspnea outcomes were observed (P > .05).

Conclusions

These preliminary data demonstrate that a preoperative RST program is safe and feasible and can improve short-term respiratory physiologic capacity (MEP and MIP) in CS patients. Future research is warranted to validate the current findings in a larger cohort of CS patients and to determine whether RST improves postoperative extubation outcomes, airway clearance capacity, and aspiration following cardiac surgery.

Characterizing Swallowing Impairment in a Post-Lung Transplant Population

BACKGROUND

Lung transplant recipients carry significant pre- and post-lung transplant dysphagia risk factors related to altered respiratory-swallow coordination as well as acute injury and decompensation resulting in the acute post-lung transplant recovery period. However, we are only beginning to understand the potential physiological contributors to altered swallowing in this population.

METHOD

A retrospective, cross-sectional, cohort study of post-lung transplant patients was performed. All participants received a modified barium swallow study (MBSS) as part of standard care during their acute hospitalization using the Modified Barium Swallow Impairment Profile (MBSImP) protocol and scoring metric. A combination of MBSImP scores, Penetration-Aspiration Scale (PAS) scores, Functional Oral Intake Scale (FOIS) scores, International Dysphagia Diet Standardization Initiative (IDDSI) scale levels, and the time from lung transplant to MBSS was collected, as well as measures of swallowing impairment and swallowing-related outcomes. Differences in swallowing physiology and swallowing-related outcomes between participants with typical versus atypical PAS were explored.

RESULTS

Forty-two participants met our prespecified inclusion criteria. We identified atypical laryngeal penetration and/or aspiration in 52.4% of our post-lung transplant cohort. Silent aspiration occurred in 75% of those patients who aspirated. Comparing typical versus atypical PAS scores, we found statistically significant associations with laryngeal elevation (Component 8), p < .0001; anterior hyoid excursion (Component 9), p = .0046; epiglottic movement (Component 10), p = .0031; laryngeal vestibule closure (Component 11), p < .0001; pharyngeal stripping (Component 12), p = .0058; pharyngeal total scores, p = .0001; FOIS scores, p = .00264; and IDDSI liquid levels, p = .0009.

CONCLUSIONS

Swallowing impairment resulting in abnormal bolus invasion is prevalent in post-lung transplant patients. Airway invasion in this cohort was related to pharyngeal swallow impairment and resulted in modified oral intake. Our findings help expand upon prior literature, which only reported the incidence of aspiration and pathological laryngeal penetration. Our results suggest that the potential for aerodigestive system impairment and negative sequela should not be underestimated in the post-lung transplant population.

Rehabilitating Cough Dysfunction in Parkinson's Disease: A Randomized Controlled Trial

BACKGROUND

Disorders of airway protection (cough and swallowing) are pervasive in Parkinson's disease (PD) resulting in a high incidence of aspiration pneumonia and death. However, there are no randomized controlled trials comparing strength and skill-based approaches to improve airway protection in PD.

OBJECTIVES

The aim of this study was to compare expiratory muscle strength training (EMST) and sensorimotor training for airway protection (smTAP) to improve cough-related outcomes in people with PD.

METHODS

Participants with PD and dysphagia were recruited for this prospective phase II randomized-blinded controlled clinical trial. Participants completed baseline assessment, 5 weeks of EMST or smTAP, and a post-training assessment. Primary outcome measures included maximum expiratory pressure (MEP) and voluntary cough peak expiratory flow rate (PEFR). Mixed effects models were used to assess the effects of EMST and smTAP on outcomes.

RESULTS

A total of 65 participants received either EMST (n = 34) or smTAP (n = 31). MEP improved from pre- to post-treatment for smTAP (P < 0.001, d = 0.19) and EMST (P < 0.001, d = 0.53). Voluntary PEFR increased from pre- to post-treatment for smTAP (P < 0.001, d = 0.19) and EMST (P < 0.001, d = 0.06). Moreover, reflex cough PEFR (P < 0.001, d = 0.64), reflex cough expired volume (P < 0.001, d = 0.74), and urge to cough (P = 0.018, OR = 2.70) improved for the smTAP group but not for the EMST group.

CONCLUSIONS

This clinical trial confirmed the efficacy of smTAP to improve reflex and voluntary cough function, above and beyond EMST, the current gold standard. © 2022 International Parkinson and Movement Disorder Society.

Rehabilitation of Airway Protection in Individuals With Movement Disorders: A Telehealth Feasibility Study

PURPOSE

Airway protective deficits (swallowing and cough) greatly reduce health and quality of life and are a pervasive consequence of neurodegenerative movement disorders. Expiratory muscle strength training (EMST) and cough skill training (CST) are two treatment approaches to improve airway protection; however, many patients are unable to access these treatments. Telehealth may improve access to care, but it remains unknown whether these treatments are feasible and efficacious via telehealth. This study aimed to determine the practical feasibility and preliminary treatment effect of EMST and CST via telehealth.

METHOD

Twenty participants with movement disorders completed 4 weeks of EMST and 2 weeks of CST, including two clinician-directed treatment sessions via telehealth and 3 days of home practice per week. Feasibility was calculated for each treatment. Practical feasibility was defined as completing treatment (EMST or CST) and obtaining the relevant outcome measures-a proxy of maximum expiratory pressure (pMEP) for EMST and peak expiratory flow rate (PEFR) for CST-within a 30-min session/period. Session factors that may have influenced feasibility were examined. Preliminary treatment effect was defined as changes in pMEP and PEFR.

RESULTS

Time taken to obtain pMEP and complete EMST was 17.48 min, and time taken to obtain PEFR and complete CST was 17.69 min. pMEP, single voluntary cough PEFR, and sequential voluntary cough PEFR increased from pre- to posttreatment.

CONCLUSIONS

Findings suggest that the delivery of EMST and CST is feasible via telehealth and yield improvements to pMEP and PEFR. This has important implications for expanding service delivery of airway protective interventions and reducing health care disparities in people with neurodegenerative movement disorders.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21357669.

A Prediction Model for Peak Expiratory Flow Derived From Venous Blood Biomarkers and Clinical Factors in Amyotrophic Lateral Sclerosis

Although peripheral venous blood biomarkers are related to respiratory function in Amyotrophic lateral sclerosis (ALS) patients, there are still few prediction models that predict pulmonary function. This study aimed to investigate the venous blood biomarkers associated with respiratory function in patients with ALS from southwest China and to create prediction models based on those clinical biomarkers using logistic regression. A total of 319 patients with ALS from the retrospective cohort and 97 patients with ALS from the prospective cohort were enrolled in this study. A multivariable prediction model for the correlation between peak expiratory flow (PEF) and hematologic, biochemical laboratory parameters, and clinical factors in patients with ALS was created. Along with female patients, bulbar-onset, lower body mass index (BMI), later age of onset, lower level of creatinine, uric acid, triglyceride, and a higher level of high-density lipoprotein cholesterol (HDL_C) were related to reduced PEF. The area under the receiver operating characteristics (ROC) curve is.802 for the test set and.775 for the validation set. The study constructed a multivariable prediction model for PEF in patients with ALS. The results can be helpful for clinical practice to predict respiratory impairment.